T. NO.

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CASTE CERTIFICATE
l S]E
SR. NO.
MAHARASHTRA OTH. STATE

Applicant Name :-
Mr./Mrs./Miss First Name Middle Name Last Name
# Certificate Required in the Name of (V nJ + iS x) -

Mr./Mrs./Miss First Name Middle Name Last Name

E-mail : Ph./Mob.: Village :
Present Address :
Caste : SC / ST / VJ / NT / OBC / SBC / MARATHA Sub Caste :
+V Yx CixS E / Application to be made by an Adult only
Attested Documents Required & Information to be Marked & Filled by the Applicant
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1 Fathers Name (with reference to # above)
2 School / College Name
3 Date of Affidavit
4 Caste Certificate (of Father / Relative) Name
5 Caste Certificate No.
6 Caste Certificate Date (of Father / Relative)
7 Caste Certificate of Father / Relative Issued By
8 Other Caste Certificate/s
9 Other Document/s
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Prarambha CC-003

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Prarambha CC-004
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No. R/ ________________ Date ________________

Solemnly affirmed and signed before me by
Shri./Smt. ___________________________________
|iY{j Eh-S I
who is identified by Shri./Smt._______________________
whom I know personally.

Executive Magistrate
 Govt. of Maharashtra, Stamp Duty Waiver Order No. Mudrank 2004/1636/PK 436 /M-1, dated 1/7/2004

Affix Rs. 5/- Court Fee Stamp AFFIDAVIT FOR

OBTAINING CASTE CERTIFICATE

I, Shri./Smt./Ku. ___________________________________________, aged _____ years, Indian

inhabitant residing at _____________________________________________________________,
Village __________________, Taluka ____________________, Mumbai Suburban District, do hereby
state and declare on solemn affirmation as under:
I say that I am residing at the above said address and I am a native and permanent resident of
___________________, Taluka ____________________, District ____________________, State
_________________. I belong to the ____________________ Caste/Tribe/Community and my Sub
Caste/Tribe is ______________________. The rituals, practices and festivals observed by our family are
as per the rituals, practices and festivals of the ____________________ Sub Caste/Tribe/Community.
* My family has converted to Buddhism and we follow the Buddhist faith.
I am making an application to the Sub Divisional Officer / Dy. Collector to obtain the said Caste Certificate
for myself/ my ___________, Shri./Smt./Ku. ________________________________ & I would be
enclosing this affidavit with the prescribed application form & other relevant proof/s.
I/My ______________ have / has previously not obtained a Caste Certificate from your office or from any
other office and no competent authority or Caste Scrutiny Committee has rejected the claim of any of my
family members.
* Applicable * My maiden name before marriage was _________________________________, but after my
ONLY in case of marriage to Shri._____________________________________________, my name has been
married women changed to ________________________________________. Both names are my names only.
applicants
Documentary evidence in the form of Marriage Certificate/Gazette Publication is attached herewith.

Family Tree
Use & Attach Separate Sheet If Family Tree
Does Not Properly Fit in the Given Space

The information given in this affidavit and the application are true to the best of my knowledge and belief. If
this information is found to be false later, I am aware that I would be liable for all actions and consequences
under sections 193(2), 199 and 200 of the Indian Penal Code.
Pl. sign. before the Executive Magistrate

Please Paste
Passport Size
Witness: Photograph of
Signature - Deponent
Name -
Address -
For office use only

No. R/ ________________ Date ________________

Solemnly affirmed and signed before me by
Shri./Smt. ___________________________________ Sign of Deponent
who is identified by Shri./Smt._______________________
whom I know personally.

Executive Magistrate