From, The Tahasildar & Taluka Executive Magistrate,

1 * Office / Office, Belgaum From, _____ _____ To, The Tahasildar & Taluka Executive magistrate , Belgaum. Sub:- ISSUE OF THE domicile CERTIFICATE REG. Sir, I, the undersigned _____ resident of _____ request for your kind consideration and necessary action. Sir, I am permanent resident of KARNATAKA STATE residing at BELGAUM since the last _____/BY BIRTH hence native of KARNATAKA STATE. I am educated at _____ and my father is educated at _____ he is doing _____ at _____ This certificate is required for _____ purpose only. Early action is requested. Thanking you.

2 Yours Faithfully, Place: Belgaum. Date: (_____) Sign of the Applicant * Office / Office, Belgaum domicile QUESTIONNAIRE QUESTIONS ANSWERS 1 What is your full name and address : 2 a) When and where were you born? b) Where were you educated? c) Have you ever been to your former native place? If so, for how many times and for how long on each occasion? When did you last visit it? If not, what prevented you from going there? : d) Are you married? If so, has your wife ever been to your native place and if yes often and how long on each occasion?

3 E) How many children, have you? Where were they or are they being educated and what are they doing? f)For how many years have you and your family been residing in State of Karnataka. g) Have you are your wife any property in your former native place or elsewhere out side the State of Karnataka? If so, where and of what description and value? h) Have you or wife or either of you ever had any immovable property in the State of Karnataka? If so, of what description and value. 3 a) When and where was your father born? b) What was or is his profession or occupation?

4 C) Where was his home or place of permanent residence at the time of your birth? d) Where was he when you attained majority? e) If he alive? If not, when and where did he die? 4 Was your father ever in the State of Karnataka if he was - a) Where was he educated? b) In ehat capacity did he come to the State of Karnataka or work there? c) How often if at all, did he leave or has he left the State of Karnataka and for how many on each occasion? d) If your father is alive, where is he and what is he doing. Has he * Office / Office, Belgaum retired, if so, how long did he remain in the State of Karnataka after retirement?

5 E) If your father is dead, had he retired before his death, if so, how long did he remain in the State of Karnataka after retirement. f) Has or had your father or mother any immovable property in the State of Karnataka or else where? If so, where and of what description and value? 5 Have or had you any brother or sisters, if so, how many? Where were they being educated? Where are they now and what are they now and what are they doing? If any of them are dead, where did thay died and what were their occupations? 6 Have you ever claimed been deemed to be a native of any place other than a place in the State of Karnataka for the purpose of your appointment to any office or for confirment upon you of any scholarship, or other privileges in that place.

6 7 a) For what purpose is the Certificate of domicile Required? b) What is your religion? c) Are you a member of a Scheduled Caste or a Scheduled Tribe or a community classified as a backward by the State Govt. (Answer Yes or No) d) If the answer to (b) above is yes, give particulars. e) Did you apply for a certificate of domicile at any time before and if so, when? Place: Date: Signature of Applicant : If it is found that the replies given by the applicant to the questions, set above, or to any of them are incorrect any admission obtained or benefit derived thereby shall be summarily concelled. * Office / Office, Belgaum CERTIFICATE OF AGE, NATIONALITY, domicile ETC.

7 , (Issued by Authorities in the State of Karnataka) On Submission of the Proof noted below. IT IS HEREBY CERTIFIED THAT Shri/Smt. _____ was borh on the _____ day of _____in the year One thousand Nine Hundred and _____ at _____ in the STATE OF KARNATAKA, within the territory of India: that he/she is a CITIZEN OF INDIA that he/she is domiciled in the State of Karnataka (add if necessary) by reasons of ; that he/she belongs to a community declared to a Schedule Caste/ Scheduled Tribe/Backward Community. PARTICULARS OF PROOF SUBMITTED : a) Answers given by the applicant on the prescribed form of Questionnaire. b) Birth/Baptism/Matriculation or School leaving or a like Certificate issed by ; c) Affidavit or declaration of d) (Other proof) Dated at _____ this _____ day of _____ No.

8 Belgaum Taluka Executive magistrate , Belgaum. Dated.