FORM - 2

[Rule 4(1)]

An Affidavit to be submitted to the Competent Authority with the

Application FORM-1 to issue a Scheduled Caste/Scheduled Caste converts to
Buddhism/De-notified Tribes ( Vimukt Jati) / Nomadic Tribes / Backward Classes
or Special Backward Category, Caste Certificate by the Applicant.

I, Shrikant Balkrishana Divekar son of Shri. Balkrishana Baba Divekar

aged 40 years, occupation Worker, my Daughter is Siddhi Shrikant Divekar aged
15 years, occupation Student, residing At Krushneshwar Nagar, Pag, village town
Tahsil Chiplun, District Ratnagiri, State of Maharashtra.
Hereby solemnly affirm as under:-
I belong to Hindu Bhoi (25) Cast /Tribe which is recognized as Nomadic
Tribes. To belong to Hindu religion.

My original place of residence is At Krushneshwar nagar, Pag Chiplun

Tahsil, Chiplun District, Ratnagiri State, Maharashtra.

No one from my relatives has been refused Nomadic Tribes Certificate in

the State of Maharashtra or any other State.
The True copy Validity Certificate received by me, viz.
(1) Shrikant Balkrishana Divekar,

Is enclosed with the application. The said person is my Father in relation.

To the best of my knowledge and belief the information given in the Application
FORM -1 and in the affidavit is based on facts and is correct.

Place: Chiplun
Signature
Date : 05/05/2018
(Shrikant Balkrishana Divekar)