IN THE COURT OF EXECUTIVE MAGISTRATE WARORA

FORM – 17 FOR STUDENTS

[rule 14]
Affidavit to be produced along with Caste Scrutiny Application Form
I Shri./Smt………………………………………………………………...
age…………..years, Occupation ………………. ,resident at …………………………… ,
hereby solemnly affirm today dated ……….. that Caste Certificate of my son / doughter
…………..……………….. Number …………………… dated ………….. given by
…………………………………….. District ………………. is submitted for the
Scrutiny .
The documents and proofs attached with the application form are
obtained by me form competent Authority.These documents are true and correct and
obtained by following proper procedure.No alteration /correction /change are made in
these documents. affirm hereby that these documents are not duplicates or bogus.
Caste Certificate of any relative from my paternal side was not
invalidates by the Scrutiny committee.
 And it is not a case that I applied any Caste Certificate Scrutiny
Committee In Maharashtra and my caste certificate is invalidated .
I will be responsible , if the documents and proof attached with the
application form are found to be 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 mentioned information is true and correct ,
hence this affidavit .

Place :- ………………………………………………
Date :- Singniture of the Declarant

Verification
Verified that the contents of above affidavit are true and correct of
the best of my knowledge and belief . I am liable u/s 193(2) , 199 and 200 of Cr . P.C /
IPC if any contents found false .

Place :- .……………………………
Date :- DEPONENT