REVENUE DEPARTMENT, GOVT.

OF NCT OF DELHI
APPLICATION FORM – SOLVENCY CERTIFICATE
APPLICANT DETAILS

1. e-DistrictRegistration Number :
(For already Registered User- Not to be filled in by first time Applicants or those having Aadhaar number)
OR
2. UID (AADHAAR) No :
3. Name of Applicant : ___________________________________________
Applicant color
4. Name of Father : ___________________________________________ Passport Size
5. Name of Mother : ___________________________________________ Photograph
Size – 5 x 4.5 (Cm.)
6. Name of Spouse : ___________________________________________ Or
7. Gender : Male Female Other 2 x 1.75 (Inch)

8. Date of Birth : DD MM YYYY

9. Present Address :
House Name/No : ______________________ Sub-Locality : ______________________
Locality : ______________________ Village/Town : ______________________
Sub- division : ______________________ District : _______________________
State : ______________________ Country : _______________________
PIN Code :
10. Whether the Present and Permanent Address is same : Yes No
11. if No, Permanent Address :
House Name/No : ______________________ Sub-Locality : ______________________
Locality : ______________________ Village/Town : ______________________
Sub- division : ______________________ District : _______________________
State : ______________________ Country : _______________________
PIN Code :
12. Mobile No. : e-Mail ID :_________________@___________
13. Total Amount for which Solvency Certificate Required : Rs. _____________________________________________
14. Purpose to obtain certificate :____________________________________________
15. Are you Salaried Employee ? : Yes No
A. If yes : Government Private Service
(Attach Last 3 Month Salary Slip and Income tax return of last 3 yearsr)
B. Details of Employment :-
i. Name of Employer:______________________ iii. Designation : ______________________
ii. Monthly salary : _____________________ iv. PAN No. :
v. Address of the Employer:-
Building/Plot Name/No : _____________________ Sub-Locality : ______________________
Locality : ______________________ Village/Town : ______________________
Sub- division : ______________________ District : ______________________
State : ______________________ Country : _______________________
PIN Code : Telephone No :
C. If Not salaried (Attach Income Tax return of last 3 years)
i. Occupation :______________________ iii. TAN/TIN NO: :
ii. Monthly Income : _____________________ iv. Bank A/c NO: _____________________________

APPLICATION FORM – SURVIVING MEMBER CERTIFICATE

 VALUATION STATUS (ALL PROPERTY VALUES MUST BE AS PER GOVERNMENT VALUER VALUATION REPORT)
16. Immovable & Moveable Assets
Particular Address Area Value Purchase Date
(Sq Mtr) (As per Govt.
Valuer Report)
Sub-Locality : ___________________
Agriculture Land
Locality : ___________________
(Attach Village/Town: __________________
a. Khatauni & khasra no. Sub-division: ___________________ DD MM YYYY
b. copy of latest fard District :___________________
c. Proof of property being free
from all encumbrances State :___________________
d. Valuation certificate) Country :___________________
PIN Code :
House
House/Building
Name/No:_____________________
(Attach Sub-Locality : __________________
a. sale deed Locality : __________________
b. Attach proof of rented value if Village/Town:__________________
any
c. Proof of property being free Sub-division :__________________ DD MM YYYY
from all encumbrances District :__________________
d. Attach proof of house tax State :__________________
e. Valuation certificate) Country :__________________
PIN Code :
Building/Plot
Plant Machinery &
Name/No:_____________________
equipment
Sub-Locality : __________________
(Attach Valuation certificate) Locality : __________________
Village/Town:__________________
Sub-division :__________________ DD MM YYYY
District :__________________
State :__________________
Country :__________________
PIN Code :
Motor Vehicles House NA
(Attach Registration Certificate Name/No:_____________________
along with insurance document) Sub-Locality : __________________ DD MM YYYY
Locality : __________________
Village/Town:__________________
Sub-division :__________________
District :__________________
State :__________________
Country :__________________
PIN Code :
17. Valuer Details
a. Registered Valuer Name : ________________________________
b. Registration No : ________________________________

APPLICATION FORM – SURVIVING MEMBER CERTIFICATE

 18. Current Assets
Particular Details
Fixed Deposits S.No. Bank Account No. Bank Name & Branch FD Amount FD Maturity Date
(If Applicable)
1. DD MM YYYY
(Attach bank
statement) 2.
DD MM YYYY
3. DD MM YYYY
4.
DD MM YYYY
Shares/ S.No. No. of Shares Shares Value Certificate No. Company Name
Debentures/Bo 1.
nds
(Attach share 2.
certificate) 3.
4.
Others
(Please Specify)

19. Identity Proof of Applicant (Please tick one, provide the document No. and attach the same )
Aadhaar Card PAN Card Ration Card with Photograph
Voter ID Card Passport Driving License
Any Govt. recognized document Document No :

20. Present Address Proof of Applicant (Please tick one, provide the document No. and attach the same )
AADHAR Card Voter ID Card Driving License
Passport Ration Card . Electricity Bill DISCOM Name___________
Water Bill Utility Name _____________________ 1. Gas Bill Comp Name _____________
Telephone Bill Company name_______________ 91 Any Govt. recognized document
Rent Agreement (Registered) Bank Passbook Document
9 No :
21. Permanent Address Proof of Applicant (Please tick one, provide the document No. and attach the same )
AADHAR Card Voter ID Card Driving License
Passport Ration Card . Electricity Bill DISCOM Name___________
Water Bill Utility Name _____________________ 1. Gas Bill Comp Name _____________
Telephone Bill Company name_______________ 91 Any Govt. recognized document
Rent Agreement (Registered) Bank Passbook Document
9 No :
Declaration
I hereby solemnly affirm & declare that, all of the above furnished information, is true & correct to the best of my
knowledge. I am fully aware that furnishing incorrect or false or forged information will lead to punitive action against
me under the relevant statutory provisions.
Date: DD MM 20YY
Applicant Signature :

Place: ______________________

APPLICATION FORM – SURVIVING MEMBER CERTIFICATE