Application for Non-Creamy Layer Certificate v0.1

1 Reference No. Application Date Application for Non-Creamy Layer New [ ] Renewal [ ]. Applicant Details Aadhaar Number Full Name *. Gender * Male [ ] Female [ ] Other [ ]. Date of Birth *. 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 Pin Code Permanent Address *. (Fill if different from above). House/Flat No. Building No. /Building Name Society/Complex Road Name Name of Post Office Pin Code Mobile No. *. Email Occupation *. Certificate Number Previous NCL. Certificate 's details (if Place of Issue applicable) * Valid till date Beneficiary Details Full Name *. Spouse Name *. Father's Name *. Mother's Name *. Address where family originally resides*. Applicant's Relation to Beneficiary *.

2 Religion *. Caste *. Occupation and Income Details of Applicant's Family * (Please fill the sections as applicable). Income from Salary/Pension Type of Occupation Father Mother Spouse Central Government [ ] [ ] [ ]. State Government [ ] [ ] [ ]. Private Sector [ ] [ ] [ ]. PSU [ ] [ ] [ ]. Armed forces [ ] [ ] [ ]. Others (Specify). Occupation Details Father Mother Spouse Name of Organization Designation/Rank Department Salary Range Total Annual Income Date of Joining (dd/mm/yyyy). If Pensioner, date of retirement (dd/mm/yyyy). Income from Business Type of Business Total Annual Income Income from Immovable property Owner of property Father [ ] Mother [ ] Minor [ ]. Location Area (Yards / Sq. Metres / Acres /. Hectares). Type of agricultural land Irrigated [ ] Dry crop [ ]. Area of irrigated land (Yards /.)

3 Sq. Metres / Acres / Hectares). a) Percentage of irrigated land as per constitutional ceiling under the state land ceiling act formula b) If you own both irrigated and dry land, percentage of irrigated land as per constitutional ceiling under the state land ceiling act formula As per a) total irrigated land as a percentage as calculated by the land ceiling act formula Cultivation details Type of cultivation Crop [ ] Fruits [ ]. Location Cultivated Area (Yards / Sq. Metres / Acres / Hectares). Details of land/building in urban area Location of property Details of property Current use of property Total Annual Family Income from all sources excluding salary and agricultural income Are you an income tax payee Yes [ ] No [ ]. (Attach assessment if yes). Have you paid wealth tax Yes [ ] No [ ].

4 (Attach details). (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 Identity Proof- Voter ID Card/ Passport/Driver's License/RSBY Card/Aadhaar Card/.

5 1. Identity card issued by Govt. or Semi Govt. organisations/PAN Card/ MNREGA Job [ ]. Card Address proof- Voter ID Card/ Passport/Driver's License/ Aadhaar Card/ Electricity 2. Bill/ Water Bill/ Extracts of 7/12 and 8 A / Rent Receipt/ Telephone Bill/ Ration [ ]. Card/Property Tax Receipt Proof of caste for self school leaving Certificate mentioning caste / Bonafide 3. Certificate (mentioning caste) issued by school / self attested Xerox of caste Certificate / If uneducated birth registration extract / Caste and residence Certificate issued by [ ]. Sarpanch/Local Police/Corporator 4. Affidavit for caste [ ]. Income proof Income tax return for previous 3 financial years, if applicant is salaried 5. or self employed or businessman / Income Certificate from Tahsildar for 3 years, if [ ]. applicant is farmer or labourer / Affidavit mentioning income for last 3 years Additional Documents to be produced as applicable 1.

6 Property tax receipt [ ]. 2. If proof of father's caste not available, a relative's caste Certificate and genealogical affidavit with details of relation to relative [ ]. 3. If applicant migrated from other state/ district, then caste Certificate of applicant's father issued by competent authority in that state/district [ ]. If married women, 4. a. Proof of caste before marriage, as prescribed in point no. 3. [ ]. b. Proof of marriage- marriage registration Certificate and name change notification in gazette If applicant is Muslim (either of the following document may be submitted). 5. a) A Investigation report of Tahsildar if his/her father's caste Certificate is not available [ ]. b) Caste Certificate issued by registered Muslim Societies Proof of caste of a relative- Father/Brother/Sister/Grandfather/Uncle/ Aunt or any other blood relation- a.

7 school leaving Certificate b. Birth/death extract 6. c. If in Government service, extract of first page of service book [ ]. d. Document certifying caste issued by department of social justice The above documents should be produced for a the applicant or applicants relative who is born on or before the following dates- OBC/SBC -13/10/1967.