REVENUE DEPARTMENT, GOVT.

OF NCT OF DELHI APPLICATION FORM FOR SCHEDULED CASTE CERTIFICATE

Warning: It is an offence to give false information in this form. 1. AADHAAR No. : (If AADHAAR not available, provide information of 2a and 2b) 2a.Enrolment No.: ___________________________________ Any one - PAN/Voter Card/I-Card/Passport/DL/Other-specify 2b.ID Proof No.: _____________________________________ 3. Mobile No. : 1. Name (in BLOCK letters) 2. Fathers / Husbands Name 3. Permanent Address : __________________________________________________ :__________________________________________________ :__________________________________________________

____________________________________________________________________________ 4. Complete present address with name of Police Station :______________________________ ___________________________________________________________________________

5. Ration Card Number

: ______________________________________________________

6. Date and place of birth :_______________________________________________________

7. Is he/she scheduled caste since birth or by adoption 8. Nationality

: ____________________________ :_____________________________

9. Caste 10. Religion 11. Duration of stay in Delhi (with date)

: ______________________________ :______________________________ : Date Month Year

12. Complete address of father before migration to Delhi : 13. If migrated after or before 20-09-1951 in Delhi, give Date of migration 14. The state to which ancestors belong to 15. Educational Qualification : Date Month Year

: ______________________________ : ______________________________

16. Name of School / College last attended : ______________________________ (attach an attested copy of the Education Certificate) 17. Purpose for which the certificate is required : ______________________________

18. Have your parents/or any of your family member been is issued Scheduled Cast Certificate from Delhi. If so, attach an attested copy of that S.C. Certificate:

_______________________________

19. Have you obtained scheduled caste certificate from Delhi or any other State? Give the answer in Yes or No: ____________________________ If Yes please give full detail 20. Name and Address of the respectable person of the locality . (1) Full Name (in BLOCK letters): _______________________________________________ Full address (House No., Street, Locality): _____________________________________ ______________________________________________________________________ (2) Full Name (in BLOCK letters) : ______________________________________________ Full address House No., Street, Locality): _____________________________________ ______________________________________________________________________

Signature of the Applicant

Declaration: (To be signed by applicant if he/she attained the age of 18 years. In case he/she is minor it will be signed by father/guardian of the applicant) I, , son of/daughter of/ wife of .. do hereby declare that the facts given in the application are correct and nothing has been concealed there from.

Signature of the applicant Name and relationship with the applicant ________________________

Caution: It is an important document and should be attested on the basis of personal knowledge. If the scheduled caste certificate is issued on the basis of wrong attestation then the action can be taken against the attestator under Indian Penal Code.

ATTESTION

I certify that Shri/Km./Smt. .son of/daughter of/wife of . is known to me for the last years and he/she belongs to caste and he/she was born at (place of birth). I also certify personally that the facts given in this form are correct.

Signature of the Attestator

Name of Attestator (in BLOCK Letters)_________________________ Office Address with Tel no. :______________________________________ Full Residential Address:______________________________________.
______________________________________________________

The above attestation can be done by any of the following officers:1. Member of Parliament/MLA/Councillor 2. Gazetted Officer of Delhi Govt. /Central Government. 3. Police Officer not below the rank of D.S.P.

List of supporting documents - (Maximum time limit 60 days)

Completed application form duly attested by MP/ MLA//Councillor/Gazetted officer. AADHAR No., if AADHAR No. is not available, provide the AADHAR Enrolment No. and any one of the identity proof PAN / PASSPORT / Driving Licence / Voters Card / Identity Card. The name of the applicant on the AADHAR card should match with the Name of the Applicant. The photograph of the applicant will be captured through web camera at the time of submission of application or at the time of verification. The Photograph of the applicant should match with photo of the applicant on the AADHAAR. A copy of SC/ST certificate of father, brother, sister or of his/her blood relative from paternal side. Affidavit in case of SC/ST certificate issued from outside Delhi in prescribed Performa attested by executive magistrate (Affidavit from the major if the children are below the 18 years.) If certificate of father, brother, sister or of his/her blood relative from paternal side is not available, two attestations by MP/MLA and Gazetted Officers, declaring the caste of applicant. Supporting document for the present residential proof like Voters Card, Electricity Bill, Water Bill, Telephone Bill etc. Proof of Date of Birth (Birth certificate, School certificate or passport) The migrants SC members whose caste are listed in SC list of Delhi should be issued caste certificate as original resident of Delhi if any of the following o o Birth Certificate (born in Delhi.) Matriculation Certificate (studied in Delhi)

Note: All supporting documents must be attested by MPs/MLAs and Gazetted officer.