I hereby certify that the above-mentioned information is true, and nothing has been concealed therein. I have read the conditions for eligibility for receiving Unemployment Allowance and confirm that I am eligible. I understand that if any of the above information is found incorrect, appropriate legal action may be taken against me.

• Place:
• Date:
• Note:

• Applicant's Signature with Name:

• 1. Please ensure that all the columns of this application form are filled.
• 2. Self Certified Declaration declaring that she/he is unemployed as per format prescribed by the Department. (as per form 'C' attached).
• 3. Attested copies of 10th / 12th / age certificate issued by competent authority to ascertain age and educational qualification is attached.

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