Form-XII – Income Aassest EWS – Certificate to be Produced by Economically Weaker Sections

FORM-XII

(Government of_______________)

(Name & Address of the authority issuing the certificate)

INCOME & ASSEST CERTIFICATE TO BE PRODUCED BY ECONOMICALLY WEAKER SECTIONS

CERTIFICATE No.________

DATE__________

VALID FOR THE YEAR

This is to certify that Shri/Smt/Kumari________________________________son/daughter/wife of__________________ permanent resident of _________________________________ Village /Street____________ Post Office________________District_______________in the State/ Union Territory_______________Pin Code____________ whose photograph is attested below belongs to Economically Weaker Sections, since the gross annual Income* of his/her family ** is below Rs. 8 Lakh (Rupees Eight Lakh only) for the financial year__________.

His/Her family does not own or possess any of the following assests***:

(I) 5 acres of agriculture land and above;

(II) Residential flat of 1000 sq. ft. and above;

(III) Residential plot of 100 sq. yards and above in notified municipalities;

(IV) Residential plot of 200 sq. yards and above in areas other than the notified municipalities.

2. Shri/Smt/Kumari_____________________belongs to the ___________caste which is not considered as a Schedule Caste, Schedule Tribe and Other Backward Classes (Central List)

Signature with Seal of Office_____________

Name_________________

Designation__________________

*Note1: Income covered all sources i.e. salary, agriculture, business, profession, etc.

**Note 2: The term “Family” for this purpose include the person who seeks benefit of reservation, his/her parents and siblings below the age of 18 years as also his/ her spouse and children below the age of 18 years.

***Note 3: The property held by a “Family” in different locations or different places/ cities have been clubbed while applying the land or property holding test to determine EWS status.

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