Annexure-I

Government of Maharashtra
Haveli
Documents
(This certificate has been issued on the basis of following proof/evidences/documents)
1. Application Form 11
2. Application Form 2
3. Appendix A
4. Appendix D
5. UID
6. School Leaving Certificate
7. UID Of Father
8. School Leaving Certificate Of Father
9. School Leaving Certificate Of Grandfather
10. Ration Card
11 . Electricity Bill
12. Income Certificate

INCOME & ASSEST CERTIFICATE TO BE PRODUCED BY ECONOMICALLY

WEAKER SECTIONS

Certificate No.: 1 I Date: 16/10/2024 1-I --•• 2

VALID FOR THE YEAReo2lo2•I

This is to certify that, 4 is Son of

------
permanent resident of Permanent Address
whose photograph is attested
below belongs to Economically Weaker Sections, since the gross annual income • of
His 'famil ' _ is below Rs. 8 lakh (Rupees Eight Lakh only) for
the financial year 2022-2023 . His family does not own or possess any of the following assets.
. acres o agncu ura an an a ove;
II. Residential flat of 1000 sq. Ft. And above; 7
6
Ill. Residential plot of 100 sq. Yards and above in notified municipalities;
IV. Residential lot of 200 s . Yards and above in areas other than the notified
municipa 1t1es.
2. 8 belong to the " ___ g ___ �aste which
is not recognized as a Scheduled Caste, Scheduled Tribal and Other Backward Classes (Central
List)

Signature valid
10
Digitally Signed by competent authority
Digital �ed by
--.i ...

Archar�W;al Nikam
Date:2023-10-16 5:58:30 PM
Place : Haveli Tehsildar
Date �2

Printed By -OMTID :MH032200757 VLE Name :Vikas Sidheshwar Sakhare, Date:16/10/2023 3:53PM
 Reference for Checklist to self-verify your GEN-EWS certificate
(Refer to the next page for description of "Point Numbers")
7
Annexure-I
Government of ………………………
(Name & Address of the authority issuing the certificate)

INCOME & ASSETS CERTIFICATE TO BE PRODUCED BY ECONOMICALLY WEAKER SECTIONS

1
Certificate No. _ _ _ _ _ _ _ _ _ 2
Date: _ _ _ _ _ _ _ _ _ _ _ _

VALID FOR THE YEAR_ _ _ _ _ _ _ _ _ 3

4
This is to certify that Shri/Smt./Kumari _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ son/daughter/wife of
5
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 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
6
Lakh (Rupees Eight Lakh only) for the financial year _ _ _ _ _ _ _ _ _ _. His/her family does not own or
possess any of the following assets***:
I. 5 acres of agricultural land and above;
II. Residential flat of 1000 sq. ft. and above; 7
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.

8 9
2. Shri/Smt./Kumari _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ belongs to the _ _ _ _ _ _ _ _caste which is not
recognized as a Scheduled Caste, Scheduled Tribe and Other Backward Classes (Central List).

10
Signature with seal of the Office _ _ _ _ _ _ _ _ _ _ _ _ _
Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Designation _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Recent Passport size

attested photograph of
the applicant

11

*Note 1: 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.
 Checklist to self-verify your GEN-EWS certificate

The benefit of reservation under GEN-EWS can be availed upon production of an Income &
Asset Certificate issued by a Competent Authority. The Income and Asset Certificate issued
by any one of the following authorities in the prescribed format (on the next page) shall only
be considered valid.

I. District Magistrate/Additional District Magistrate/ Collector/ Deputy

Commissioner/Additional Deputy Commissioner/ 1stClass Stipendiary Magistrate/
Sub-Divisional Magistrate/ Taluka Magistrate/ Executive Magistrate/ Extra Assistant
Commissioner

II. Chief Presidency Magistrate/Additional Chief Presidency Magistrate/

Presidency Magistrate

III. Revenue Officer not below the rank of Tehsildar and

IV. Sub-Divisional Officer or the area where the candidate and/or his family normally resides.

To ensure the validity of the certificate, please adhere to the following checkpoints. Each checkpoint is
marked in red on the format and must be completed correctly:

1. Certificate Number: Ensure that the Certificate No. is provided.

2. Date of Issue: The certificate must be dated on or after April 1, 2024.
3. Valid for the Year: The year should be specified as 2024-25.
4. Candidate’s Name: Enter the candidate's full name in the designated field.
5. Parent’s Name: Include the name of either the Father, Mother, or Husband in the relevant
field.
6. Financial Year: As the certificate’s validity year is 2024-25, the Financial Year must be
2023-24.
7. Asset Conditions: Sections I to IV must detail all asset conditions exactly as specified in
the format. Ensure that measurements align with those provided in the format;
deviations in measurement units should not exceed the specified size.
8. Candidate’s Name (Repetition): Reconfirm that the candidate’s name is included in
the appropriate field.
9. Caste Information: Specify the caste to which the candidate belongs in the designated field.
10. Signature & Seal: For non-digital certificates, the Issuing Authority’s signature and seal
must be included, along with their name and designation. (Not required for digitally
signed certificates)
11. Photograph: Attach the candidate's recent passport-size photo and ensure it is attested.
Note: Attestation is not required for digitally signed certificates.
Note: Before uploading your certificate, verify that it meets all the above requirements and is clearly
readable.
 SAMPLE FORMAT of EWS Certificate
7
Annexure-I
Government of ………………………
(Name & Address of the authority issuing the certificate)

INCOME & ASSETS 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 assets***:
I. 5 acres of agricultural 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

recognized as a Scheduled Caste, Scheduled Tribe and Other Backward Classes (Central List).

Signature with seal of the Office _ _ _ _ _ _ _ _ _ _ _ _ _

Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Designation _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Recent Passport size

attested photograph of
the applicant

*Note 1: 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.