FORM-17

[rule 14]
Affidavit to be produced along with Caste Scrutiny application Form

I, Shri/Smt./ …....................................................................................................................................
age……………………………………… years, Occupation ………………………....................................
residing at…………………………………………………………………………………………………...
hereby solemnly affirm today dated ............................................................................. that caste certificate
of my son/ daughter Number .................................................. dated .............................................. given by
Tahasildar and Executive Magistrate / Deputy Collector / Sub Divisional Officer………………... District is
submitted for the Scrutiny.
The documents and proofs attached with the application Form are obtained by me from Competent
Authority. These documents are true and correct and obtained by following proper procedure. No alteration
/ correction / change are made in these documents. I affirm hereby that these documents are not duplicate or
bogus.
*Caste Certificate of any relative was not invalidate by the Scrutiny Committee.
*And it is not a case that I applied before any Caste Certificate Scrutiny Committee in Maharashtra
and my caste certificate is invalidated.
I will be responsible, If the documents and proofs attached with the application form are found
incorrect or bogus, and I am aware that I will be liable for punishment under provision of Indian Penal
Code.
I declare that the above mention information is true and correct, hence this affidavit.

Place:
Date:

(*Delete which is not applicable)

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Signature of the Declarant