Applicantion Number : : Date : : 13-10-2020

To
The Principal Secretary,
Backward Classes Welfare Department
Through:
PO cum DWO/DWO

Subject: APPLICATION FOR INCENTIVE OF INTERCASTE MARRIAGE

A. Particulars of the Applicant :

1. Name :
2. Father's Name :
3. Date of Birth : 01-01-1970
4. Sub Caste(in case of SC) :
5. Address:
a. House No. :
b. Post Office :
c. Police Station :
d. Pin Code :
e. Sub Division :
f. District :
6. Contact Number :

B. Particulars of the Spouse :

1. Name :
2. Father's Name :
3. Date of Birth : 01-01-1970
4. Sub Caste(GENERAL) :
5. Address:
a. House No. :
b. Post Office :
c. Police Station :
d. Pin Code :
e. Sub Division :
f. District :

C. Marriage Details :

1. Date of Marriage : --
2. Details of Marriage Registration Certificate : NO
3. Whether Living together : NO

D. Other :

1. Whether Any Child is born out of this Wedlock : NO

2. Whether Any Such grant has been received earlier from : NO
any authority
Declaration: We hereby declare that above information are true to the best of our konwledeg and we shall be entirely responsible for these
information. We understand that the grant amount will be forfeited if any of the information is found incorrect.

Date: Co-Applicant Signature Applicant Signature

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