application for caste certificate- scheduled caste ... form for... · extract of primary school...
TRANSCRIPT
Application for Caste Certificate- Scheduled Caste/Scheduled Caste converts to Buddhism/De-Notified Tribes (Vimukt Jati) Nomadic
Tribes/Other Backward Classes/ Special Backward Category Applicant Details
Aadhaar Number
Full Name *
Gender * Male [ ] Female [ ] Other [ ]
Date of Birth * DD MM YYYY
Occupation of Applicant*
Residence Address * (Please provide the following
details)
House/Flat No.
Building No. /Building Name
Society/Complex
Road Name
Name of Post Office
Village Taluka
District Pin Code
Permanent Address * (Fill if different from above)
House/Flat No.
Building No. /Building Name
Society/Complex
Road Name
Name of Post Office
Village Taluka
District Pin Code
Mobile No. *
Occupation *
Caste Details
Applicant’s Father’s Details
Full Name *
Address * (If not alive, address of his last
Reference No.
Application Date D D M M Y Y Y Y
residence )
House/Flat No.
Building No. /Building Name
Society/Complex
Road Name
Name of Post Office
Village Taluka
District Pin Code
Occupation *
Certificate applied for *
Scheduled Caste
[ ]
De-notified Tribes
(Vimukt Jati)
[ ]
Nomadic Tribes
[ ]
Other Backward
Classes
[ ]
Special Backward Category
[ ]
Sub Caste*
Beneficiary Details
Full Name *
Date of Birth * DD MM YYYY
Applicant’s Relation to Beneficiary *
Place of Birth * Village Taluka
District
Ordinary place of residence (if different from above)
Village Taluka
District
Year of Migration *
Reason for migration *
Education details of Beneficiary *
Qualification Board/university Name & Address of Institute Start Year End Year
Whether applicant’s relative been issued a caste certificate or availed Govt. benefits on the basis of caste/tribe claim*
Yes [ ] No [ ]
Details of benefits availed
Have you applied before Yes [ ] No [ ]
for Caste Certificate (including other states) *
If yes, details of application
Was certificate given Yes [ ] No [ ]
Place of application
Date of application DD MM YYYY
(Fields marked with * are mandatory)
Self-Declaration
I ______________________________________________son/daughter of ________________
_________________________ aged ________ occupation ________________________
hereby declare that the information provided above is true and correct to the best of my
knowledge, information and belief. I fully understand the consequence of giving false
information. If the information as given above is found to be false, I shall be liable to
prosecution and punishment under section 199 and 200 of IPC 1960 and/or any other law
applicable thereto.
Place : _________________ Applicant Signature : ____________________________
Date : ___ / ___ / ________ Applicant Name : ____________________________
List of documents to be attached
(mark [√] in case necessary annexure are attached else mark [X])
Mandatory Documents
1. Identity Proof- Voter ID Card/ Passport/Driver’s License/RSBY Card/Aadhaar Card/ Identity card issued by Govt. or Semi Govt. organisations/PAN Card/ MNREGA Job Card
[ ]
2. Address proof- Voter ID Card/ Passport/Driver’s License/ Aadhaar Card/ Electricity Bill/ Water Bill/ Extracts of 7/12 and 8 A / Rent Receipt/ Telephone Bill/ Ration Card/Property Tax Receipt
[ ]
3. Affidavit for Caste Certificate (Form 2) [ ]
4.
Proof of caste of a self or blood relative-
a. Extract of primary school admission register of the applicant, his father or grandfather/Primary School Leaving Certificate of the applicant or his father
b. Extract of birth register of the applicant/father/or relatives
c. An extract of Government Service Record (book) mentioning caste/community category of applicant’s father or relative
[ ]
d. Document certifying caste issued by department of social justice
e. Validity Certificate if any of father or relative which is issued by scrutiny committee
f. Copy of revenue records or village panchayat record
g. Documentary evidence in regard to the caste and ordinary place of residence prior to the date of notification of the caste
h. Other relevant documentary evidence issued by competent authority
Additional Documents to be produced as applicable
5. If proof of father’s caste not available, a relative’s caste certificate and genealogical affidavit with details of relation to relative (Form 3)
[ ]
6.
If married women,
a. Proof of caste before marriage, as prescribed in point no. 4
b. Proof of marriage- marriage registration certificate and name change notification in gazette
[ ]
7. If applicant migrated from other state/ district, then caste certificate of applicant’s father issued by competent authority in that state/district
[ ]
8. In case of religion conversion then Proof of caste before conversion, as prescribed in point no. 4
[ ]