I, Sri /Smt ——————————- s/o /w/o / d/o ———————– by faith ——–by

occupation service /business aged about ——-years at present residing at ———P.O. —————–Dist ———–

—— State ———— Pin Code — do hereby solemnly declare affirm as follows :-

1. That I am a citizen of India/Non-Resident Indian.

2. That I do not own house or flat or a building or building site or land either in my own name or in the name of my family as defined under Section 16( 3 ) of the W.B.C.S Act, 2006 in the ————- ( KMAH area / New Town area / —— City / Town / Village ) where the proposed cooperative society is located.

3. That I intend to be a member of the proposed ————–Housing Cooperative

/Cooperative Housing Society having its registered office at ————— P.O. ——-

Dist ——————– pin —————- for the purpose of owning a flat in the land of the

housing project of the said Cooperative Society which is going to be constructed for

residential accommodation of myself and members of the family.

4. That I am a permanent resident in the State of ———— and I am a citizen of India or  I intend to reside in West Bengal permanently within a period of one year from the date of application. 5. That I am not a member of any other housing cooperative society in West Bengal.

6. That I have genuine need for housing or additional accommodation from such

cooperative society.

7. That I have not entered into any contract with the …………………… Housing

Cooperative Society Ltd in the matter of any work constructional or otherwise relating

to a project of the cooperative society.

 I,……………………………………….. s/o /w/o / d/o ———————– aged about ——-years, resident of …………………………. in the State of West Bengal, do hereby declare that the information given above and in the enclosed documents is true to the best of my knowledge and nothing has been concealed therein .I am well aware of the fact that if the information given by me is proved false/not true at any point of time, I will have to face punishment as per any provision of law for the time being in force as well as the benefit availed of by me or the benefit accrued to me will be summarily cancelled.


Place: Signature of the Applicant

Note- (1) Do not type the word /s which are not applicable in your case

(2) Please fill up present and permanent address, age etc in conformity with the application form.

(3) In case of married female please record the name of the husband.

(4) For the purpose of Section 16 (3) of the WBCS Act, 2006 a family should be deemed to consist of husband, wife, minor sons & daughters, dependent widow of a predeceased son, husband and wife’s dependent parents and dependant divorcee daughter.

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