DECLARATION

I.......................................................................................................................................resident of H.No...............................................................................................................do hereby 
Certify that the following members of the family and I are living in the same household at the above address and our staple food is .....................and I am solemnly affirm that the particulars given are true and correct.

II. ( To be filled in by the head of the family/Enquiry Officer in case the head of the family is illiterate

S.No.	Names of	    Age		Nameof		Relationship	Profession		Annual	Remarks		members	 		father/		with head of			income
		 		husband		family

1	2	     3	                     4                                        5	      	   6                 	7	     8

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Details of Lands(in Acres)

III.Declaration form No.on current Household Supply Card:

Date:		Signature of Enquiry Officer			Signature or Thumb impression of

							Head of the family