Applicant's Details :
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1
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a
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Applicant's Name : *
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First Name
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Middle Name
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Last Name
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Present Residential Address : *
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Pin
code :
Ward :
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Mobile :
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b
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Occupation :
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c
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Family Business :
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Applicant's Father's Details :
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2
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a
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Father's Name :
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First Name
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Middle Name
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Last Name
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Father's Residential Address :
(If not alive, his last address)
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Pin
code :
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b
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Father's Present occupation :
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c
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Father's traditional Business :
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General Family Details :
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3
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a
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(i) Name of Scheduled Tribe : *
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(ii) Sub-caste : *
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b
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(i) Mother Tongue :
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(ii) Primarily spoken language :
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Details of Person seeking caste certificate :
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4
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Name : *
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First Name
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Middle Name
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Last Name
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a
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Native place :
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b
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If not at Native Village, then present Location name & Address
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c
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Year of Leaving Native Place
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d
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Reason for leaving home village/town/city :
(Eg. for Education, Service, etc)
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e
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Reason for staying in present Location (Eg., Education, Job, etc.)
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f
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Place of Birth
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g
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Primary School Name
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h
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Primary School Address (Village, Tahsil, District)
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i
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Secondary / High School Name
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j
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Secondary / High School Address (Village, Tahsil, District)
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5
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1
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Proof of Scheduled Tribe Caste :
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a
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1) An Extract from Birth record books of the birth record of Applicant / Applicant's
Father / Old Relative of Applicant's Father
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2) Extract from School Records of School Admission of Applicant/ Applicant's Father
/ Old Relative of Applicant's Father
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3) Primary School Leaving Certificate of Applicant / Applicant's Father
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b
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Proof of Scheduled Tribe Caste & Address before Schheduled Tribe Notification
date
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c
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If Applicant's Father of Blood Relative is working in Govt. Service, then Extract
from Service register, where Caste is mentioned
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d
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Validity Certificate provided to Applicant's Father / Father's Brother / Father's
side Old Relative by Scheduled Tribe Screening Committee
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e
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If so, then Revenue Records or Gram Panchayat records
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f
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Other proof :
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5
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2
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Additional Information
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a
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Name of 5 villages where Applicant's Relatives are staying
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b
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Name of Gods / Deities of Scheduled Tribe Caste
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c
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If Applicant has changed religion, name of Gods / Deities before change of religion
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6
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Native Place, Tahsil & District of Applicant's father / Grandfather
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7
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If yes, proof of Native Place
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8
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a
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Has Father or Close Relative taken Scheduled Tribe Certificate or Official Benefits
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b
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Affidavit attached along with application as per Sample A-1
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9
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a
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Has Applicant applied with competent authority for Caste Certificate earlier
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If yes, Name of competent authority who issued
caste certificate :
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b
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Has validity Certificate been provided to Father or any Old relative from Father's
side?
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If yes who got it & when (Attach true Copy)
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Please bring following document proofs:
- School leaving certificate / Bonafide Certificate. caste must be mentiioned
- Voter ID Card.
- School leaving Certificate of Parent or Guardian -(e.g.
Father, Uncle, Brother, Grand Father, Father's Sister, Cousin Brother, Cousin Uncle,
Cousin Grandfather or Great Grandfather) or Village Form No. 14
- Affidavit in Prescribed Format
a) All submitted documents with their details should be mentioned in Affidavit.
b) Any mistake in Name/Surname should be mentioned in detail with reasons in Affidavit.
c) If Caste proof is of Grand Father/Great Grand Father/Cousin Uncle/Cousin Brother/Cousin
Grand Father, etc. then Family Tree should be mentioned in Affidavit.
- Caste Certificate of Parents i.e. Father/Grandfather/Aunty
(Father's Sister)/Uncle (Blood Relation). Please Note that the Caste Certificate
should have been issued by Competent Authority or Caste Validity Certificate issued
by Caste Scrutiny Committee/ Village No.14, Service Book relevant page extract copy
where caste is mentioned.
- Residential proof for SC-
10-08-1950, for VJ/NT-21-11-1961 & for OBC & SBC- 21-10-1967
- Community Certificate (Samaj Certificate)
- Government Gazette Copy required if there is a change
in name.
- For Married Women, Government Gazette, Change Name Copy
or Marriage Certificate is required.
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