FORM OF CERTIFICATE TO BE PRODUCED BY BACKWARD CLASSES

FOR CLAIMING RESERVATION AND / OR AGE CONCESSION.

Serial No. District Code:

Mandal Code: Village Code:

Certificate No.

1) This is to certify that Sri/Smt/Kum________________________________

Son/Daughter of Sri _________________________________________ of
Village/Town_____________________Mandal________________ District
_________________ of the state of Andhra Pradesh belongs to ________
Community which is recognized as B.c. sub–group ___________

2) It is certified that Sri/Smt/Kum __________________________ is a native

of ___________________ Village/Town ____________________ Mandal
____________________ District of Andhra Pradesh.

3) It is certified that the place of birth of Sri/Smt/Kum _________________ is

____________________ Village/Town _____________________ Mandal
________________ District of Andhra Pradesh.

4) It is certified that the place of birth of Sri/Smt/Kum _________________ is

___________________Village/Town_______________________ Mandal
________________ District of Andhra Pradesh.

5) It is certified that Sri/Smt/Kum ___________________________ does not

belong to the section of Creamy layer as per G.O. Ms. No. 3, Backward Classes
Welfare (C2) Department dated 04-04-2006 of the Government of Andhra
Pradesh. (* Strike out if it is not applicable)

Signature:

Date:
Name in Capital Letters:

Designation:

(Seal)