Application for Caste Certificate- Scheduled Caste ...

1 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. * Email 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.

2 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.

3 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.

4 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.

5 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 [ ]