94 1 [ANNEXURE-I to Form C, C2 & C3 of the WBPDS (M&C) Order, 2013 [To be customized as per requirement] AFFIDAVIT 1, Sri/Smt./. ......................................................................................................................., S/O or D/O or W/O..................................................................................aged about..................years, by religion ......................................... by occupation .................... by nationality .....................................residing at .................................................................. P.O. .............................................................................. P.S. ............................................................ Dist ...............................................West Bengal, do hereby solemnly Dist.... affirm and declare as follows: 1. That I am a citizen of India. 2 .That I have made an application for license of an FPS Dealer. 3. That I am not a person holding a license of FPS dealer or distributor or wholesaler in my name or not belonging to a family which already has a dealer or distributor or wholesaler license. 4. That I am a member of local bodies, local authority , Panchayati Raj Institutions, board or corporation, or member of Legislative Assembly or a Member of Parliament 5. *That I am presently holding the post /employment in.............................................. (mention the name of the organization) Or That I am not holding the post/employment in the establishment of any State Government or Central Government or any authority or body or institution of Local self- government established or constituted by or under the Constitution or by any other law made by the Parliament or a State Legislature or by notification issued or order made by the Central Government or a State Government. 6. That my occupation is Business/ Unemployed * (in case of business, give details, i.e. Company/Firm name, address, phone no. etc.). 7. I am Income Tax assessee registered in the Income Tax Ward No.................... ..............with Permanent Account No.................... and my Taxable income in the last three assessment year are as follows: Assessment Year Taxable Income Total Income Tax paid Or 1 Annexures-I and II subs, by cl. (5) of the Notification No. 2596-FS/Sectt/Food/4P-09/2012 (Pt.II) dated 9th August, 2021 (w.e.f.9.8.2021) for existing Annexure-l appended with Form C.