First appeal under section 6(1) of the Uttar Pradesh Janhit Guarantee Adhiniyam, 2011

To: The Sub-Divisional Magistrate, [tehsil or sub-division name], [district]

1. Name and address of the appellant: [your full name and address, mobile number]
2. Name and address of the designated officer: Tehsildar, [tehsil name], [district]
3. Service applied for: Income certificate, application number [number], submitted on [date]
4. Order appealed against: [the rejection order dated (date), in short] OR [no decision within 20 working days; the time limit ended on (date)] OR [the application was not acknowledged; it was given on (date) to (name and address of the officer)]
5. Grounds of appeal: [why the rejection is wrong, or that no certificate was issued within the time limit]
6. Relief sought: Direct the designated officer to issue the income certificate, and take action under section 7 of the Act.
7. Other information: [anything else that helps]

Documents attached:
(a) Self attested copy of the rejection order or the acknowledgement
(b) Copies of the documents referred to above
(c) Index of documents

Place: [place]
Date: [date]
Signature: [your signature]