| 1. |
Name of the Applicant |
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....................... |
| 2. |
Father's Name of the Applicant |
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....................... |
| 3. |
Applicant's marital status : |
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Married/Unmarried |
| 4. |
Name of the Husband (in case of femaleapplicant)
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................. |
| 5. |
Date of Birth of Applicant |
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................ |
| 6. |
Caste (For SC only) |
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..................... |
| 7. |
Present Address in full |
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Mohalla/Ward............. |
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Village/Town/City........ |
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Block............Tehsil........ |
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District................. |
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State.................... |
| 8. |
Permanent Address in full |
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Mohalla/Ward............. |
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Village/Town/City........ |
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Block............Tehsil......... |
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District................. |
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State.................... |
| 9. |
Applicant's Date of Birth |
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(a) if before 10/08/50 for SC and 6/9/50 for ST; |
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Mohalla/Ward........... |
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Village/Town/City...... |
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(b) if before 26/12/84 for OBC then, place ofbirth of applicant; or if after these dates then permanentresidential address of his Father/ Ancestor
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Block...........Tehsil...... |
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District.................State............. |
| 10. |
Head of the Family residing on theabove-mentioned address on the above-mentioned date
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: |
Name.......................... Relation with theApplicant..........
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| 11. |
Details of the places where the Applicant/hisfather/ancestors have stayed from 10-8-1950 (with respect to SC),6-9-1950 (with respect to ST) and 26-12-1984 (with respect toOBC) till the present day
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: |
.................. |
| 12. |
Applicant's Caste/Tribe (including sub-caste) |
: |
............ |
| 13. |
Whether it is prescribed for the State or theDistrict vide Notification dated 26-12-1984, as amended for OBCunder Madhya Pradesh Reorganisation Act, 2000 ? If yes, itsserial number
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....................... |
| 14. |
Attach attested copies of the followingdocuments :
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Details of the attached documents |
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(1) Below-mentioned documents ofApplicant's/father/ancestors mentioning their caste : -
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(a) Revenue document of ancestors (case file); |
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(b) Jama-Bandi (Survey) or Girdawari B1; |
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(c) State Settlement; OR |
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(d) Document of Rights (1954); OR |
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(e) Survey of Forest Department/Forest RightsCertificate; OR
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(f) Admission Register of educationalinstitution; OR
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(g) Register of Birth or Death; OR |
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(h) National Register of Citizens (1949); OR |
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(i) Copy of Caste Certificate, issued earlier toFather, Ancestor or a relative; OR
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(j) Census (1931). |
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(2) Such domicile certificate or any otherdocument verifying that ancestors of the applicant were residingin the geographical limits of Chhattisgarh before the date10-8-1950 (Scheduled Castes), 6-9-1950 (Scheduled Tribes) or6-12-1984 (Other Backward Classes);
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(3) Family Tree commencing from ancestors toCaste certificate holder as obtained by Patwari.
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Yes/No |
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(4) If applicant's father is/were an employee ofState Government and in relation to SC/ST/OBC, before dated10-8-1950, 6-9-1950, 26-12-1984 where resident of existing Stateof Madhya Pradesh and were allocated to the State of Chhattisgarhon State Reorganization, related documents
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Yes/No |
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(5) If the applicant belongs to OBC and hisfather/mother is a government employee, document verifying theirpost and income certificate or copy of Form 16 of the precedingfinancial year
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Yes/No |
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(6) Envelope having full and legible address ofthe Applicant bearing adequate postage stamps (in case thecertificate is desired through post)
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Yes/No |
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(7) Affidavit of the Applicant (prescribed inFORM-2A).
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Yes/No |