Full name and address of the declarant :____________________________________________

   ____________________________________________________________________________

Particulars of transaction :

1.Details of documents being produced in support of address in column (1) Yes/No

  I do hereby declare that my source of income is from agriculture and I am not required to pay   Income Tax on any other income if any

Date :
Place :                                                                            _____________________

                                                                                      Signature of the declarant
 Verification

I ,___________________________ do hereby declare that what is stated above is true to the

best of my knowledge and belief.

Verified today, the _____________ day of ____________20_______

                                                                                                _____________________
                                                                                               Signature of the declarant
Place:_________________

Instructions : - Documents which can be produced in support of the address are :-
                (a) Ration Card.
                (b) Passport.
                (c) Driving Licence.
                (d) Identity Card issued by any institution.
                (e) Copy of the electricity bill or telephone bill showing residential address.
                (f) Any documentation or communication issued by any authority or Central
                    Government, State Government or local bodies showing residential address.
               (g) Any other documentary evidence in support of his address given on the
                    declaration.