Please affix required stamps before submission FROM No.V (See Rule 3) Office of the .... Miscellaneous Certificate Case No... of 200.. INCOME CERTIFICATE This is to certify that Shri/Smt./Miss ........... son/daughter/wife of Shri ........ Is a resident of Village/Town ........ P.S......Tahasil ......... in the District of ...... in the State of Orissa has an Annual Income of Rs. ....... (Rupees ...........)only from the sources specified below: Source Annual Income (Rs) Agriculture: Salaries: Any other source(s) (to be specified) 2. This certificate being granted only for the purpose of .......... Signature of Revenue Officer Date: Designation (with seal of office) Signature of the applicant
