Department of Welfare of SC / BC

Issuance of Caste Certificate (General)

Official Use Only ਕੇਵਲ ਦਫਤਰੀ ਵਰਤ ਲਈ nko Nh n?; ;oft; e'v /RTS Service Code: 105

Application Number / ਅਰਜੀ ਨੰਬਰ : Date of Application / ਅਰਜੀ ਦੀ ਿਮਤੀ

Name of Block & Tehsil /ਬਲਾਕ /ਤਿਹਸੀਲ ਦਾ ਨ

Fields marked with asterisk (*) are mandatory/ ਿਜਹੜੇ ਫੀਲਡ ਤੇ ਤਾਰਾ fuzB (*) ਲਿਗਆ ਹੈ, T[j ਭਰਨ ਜਰੂਰੀ ਹਨ
Part – 1 Personal Details / ਿਵਅਕਤੀਗਤ ਵੇਰਵਾ

Details of Person Filling the Application Form / noIh ਫਾਰਮ ਭਰਨ ਵਾਲੇ ਿਵਅਕਤੀ ਦਾ ਵੇਰਵਾ
1. Name / ਿਬਨਕਾਰ ਦਾ ਨ Self Attested Photo of
2. Address / ਿਬਨਕਾਰ ਦਾ ਪਤਾ Beneficiary
bkGgkso dh ;t?^s;dheP[dk
3. Relation with Beneficiary / ਿਬਨਕਾਰ ਦਾ ਲਾਭਪਾਤਰ c'N'
ਨਾਲ ਿਰਸ਼ਤਾ
Personal Data of Beneficiary / ਲਾਭਪਾਤਰ ਦਾ ਿਵਅਕਤੀਗਤ ਡਾਟਾ
4. Name / ਨ *
5. Gender / ਿਲੰਗ * Male / ਪੁਰਸ਼ Female / ਔਰਤ
6. Date of birth / ਜਨਮ ਿਮਤੀ 7. Age (if Date of birth not known)/
ਉਮਰ (ਜੇਕਰ ਜਨਮ ਿਮਤੀ ਨਹੀ ਪਤਾ)
8. Place of Birth / ਜਨਮ ਅਸਥਾਨ
9. Father's Name / ਿਪਤਾ ਦਾ ਨ *
10. Mother's Name / ਮਾਤਾ ਦਾ ਨ
11. Address / ਪਤਾ *

PIN Code / ਿਪੰ ਨ ਕੋਡ District / ਿਜ਼ਲਾ *

12. Marital Status / ਿਵਆਹ ;fEsh 13. Spouse Name / ਪਤੀ / ਪਤਨੀ ਦਾ ਨ
14. Email ID / ਈਮੇਲ ਆਈ ਡੀ 15. Contact Phone Number /ਸੰ ਪਰਕ
ਲਈ ਫੋਨ ਨੰਬਰ *
16. Voter ID Card Number / ਵੋਟਰ ਆਈ ਡੀ ਕਾਰਡ
ਨੰਬਰ
17. Aadhaar Number (UID) / nkXko ਨੰਬਰ (ਯੂ ਆਈ Aadhaar Enrollment Number (if
Aadhaar not issued)/ nkXko ਇਨਰੋਲਮਟ
ਡੀ)
ਨੰਬਰ (ਜੇਕਰ nkXko ਨੰਬਰ ਜਾਰੀ ਨਹ ਹੋਇਆ)

Part – 2 Service Details / ਸੇਵਾ ਦਾ ਵੇਰਵਾ

Application Details / noIh ਦਾ ਵੇਰਵਾ

□ Sewa Kendra / ਸੇਵਾ ਕਦਰ

18. Mode of Delivery of Service/ ਸੇਵਾ ਦੀ ਅਦਾਇਗੀ ਦਾ ਤਰੀਕਾ *
□ By Post/ ਡਾਕ ਦੁਆਰਾ

19. Application processing Office / ਅਰਜੀ ਕਾਰਵਾਈ ਦਫ਼ਤਰ

Service Details / ਸੇਵਾ ਦਾ ਵੇਰਵਾ
20. Caste belongs to/;pzXs iksh
21. Reason for the Issuance of Caste Certificate/iksh ;oNhfce/N ikoh eoB bJh ekoD

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Part -3 List of Required Documents / ਜ਼ਰੂਰੀ ਦਸਤਾਵੇਜ ਦੀ ਸੂਚੀ . Please tick (√) the document attached / ਿਕਰਪਾ ਕਰਕੇ ਨੱਥੀ ਦਸਤਾਵੇਜ ਨੂੰ ਿਟੱ ਕ (√) ਕਰੋ

1 Report from concerned Patwari & Nambardar / Sarpanch Mandatory

/ M.C.

;pzXs gNtkoh$Bzpodko$;ogzu$n?wH;h s'A fog'N

2 Self Declaration from Applicant Mandatory

fpB?eko s'A ;t?^x'PDk gZso

3. Any Two Residence Proof – Voter Card / Driving License Mandatory

/ Electricity Bill.

e'Jh th d' fojkfJPh d/ go{c t'No ekov$vokfJftzr

bkfJ;?A;$fpibh fpb

4. ID proof – Aadhar Card. Mandatory

gfjukD gZso nkXko ekov

5. Attested Copy of Age Proof Mandatory

T[wo d/ go{c dh s;dheP[dk ekgh

I confirm that I have been residing in India for at least 182 days in the preceding 12 months & information
(including biometrics) provided by me to the UIDAI is my own and is true, correct and accurate. I am aware that
my information including biometrics will be used for generation of Aadhaar and authentication. I understand that
my identity information (except core biometric) may be provided to an agency only with my consent during
authentication or as per the provisions of the Aadhaar Act. I have a right to access my identity information
(except core biometrics) following the procedure laid down by UIDAI . / w?A s;dhe eodk jK fe w?A fgSb/ 12

wjhfBnK ftZu xZN'FxZN 182 fdBQK s'A Gkos ftZu ofj fojk jK ns/ w/o/ tb'A :{ankJhaJ/avhankJh B{z fdZsh rJh
;{uBk (;w/s pkfJUw?fNqe) mhe tk do[Z;s j? . w?A fJ; sZE s'A ikD{ jK fe w/oh ;{uBk (;w/s pkfJUw?fNqe)
gqwkfDe ns/ nXko pDkT[D bJh tosh ikt/rh . w?B{z gsk j? fe gqwkfDesk d'okB w/oh fJj ;{uBk (f;tkJ/
e'o pkfJUw?fNqe d/), fe;/ th J/iz;h B{z w/oh ;fjwsh Bkb iK nXko n?eN d/ T[gpzXK nB[;ko jh gqdkB ehsh
ikt/rh . :{ankJhaJ/avhankJh tb'A fBoXkos gqfefonk ngDkT[D T[gozs w?B{z nkgDh fJ; ;{uBk (f;tkJ/ e'o

pkfJUw?fNqe d/) sZe gj[zu dk jZe jk;b j? ਅਤੇ ਮ ਸੱਚੇ ਿਦਲ ਿਬਆਨ ਕਰਦਾ / ਕਰਦੀ ਹਾਂ ਿਕ ਉੱਕਤ ਵੇਰਵੇ ਸਹੀ

ਹਨ ਅਤੇ ਕੋਈ ਜਾਣਕਾਰੀ ਛੁਪਾਉਣ / ਗਲਤ ਿਬਆਨੀ ਲਈ ਮ ਿਨੱ ਜੀ ਤੋਰ ਤੇ ਿਜੰਮੇਵਾਰ ਹੋਵਾਂਗਾ / ਹੋਵਾਂਗੀ

Citizen’s Signature / ਿਬਨੈ ਕਾਰ ਦੇ ਹਸਤਾਖਰ

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 Self-Declaration$x'PDk gZso
I _____________Son/Daughter/Wife of Sh________________Resident of________________________

District _____________, Punjab and hereby solemnly declare as under:-

w?A________________ g[Zso$g[Zsoh$gsBh ;qh________________ tk;h________________ fIbQk _____________,ਪੰ ਜਾਬ dk t;Bhe jK

ns/ j/m fby/ nB[;ko fpnkB eodk$eodh jK feL^

1. That I belong to______________ caste, My occupation is ________________ and no member of my family is

servicing in any Govt. Department My and my family incomes from all sources are Rs.________. This
income certificate is required to me or for my minor boy/girl_______________.
fJj fe w?A________________ iksh Bkb ;pzX oZydk$oZydh jK.w/ok feZsk ________________ j? ns/
w/o/ gfotko dk e'Jh th w?Apo ;oekoh ftGkr ftZu B"eoh BjhA eodk$eodh j?.w/oh ns/ w/o/ gfotko d/
;ko/ t;hfbnK s'A nkwdB________________ j?. fJj nkwdB ;oNhfce/N w?B{z y[Zd$nkgD/ Bkpkfbr
bVe/$bVeh bJh b'VhAdk j?.
2. That no certificate of this kind has been issued to me earlier, if issued then it is issued long time ago.
fJj fe w?B{z gfjbK nfijk e'Jh ;oNhfce/N ikoh BjhA ehsk frnk j?, i/eo ikoh ;[dk j? sK T[j pj[s
gfjbK dk j?.
3. That there is no any criminal case registered against me for which I have not deprived of from issuance of this
certificate. The information and the reports that are given for issuance of certificate is true and correct.
fJj fe w/o/ fto[ZX e'Jh th c"idkoh e/; BjhA uZb fojk j? fi; ftZu w?B{z fJ; ;oNhfce/N s'A tKM/ oZfynk
frnk j't/.w/o/ tZb'A fdZsh rJh doyk;s ns/ T[; ftZu doi fog'oNK T[es ;oNhfce/N ikoh eoB bJh ;jh
tk do[;s jB.

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 Self- Declarant (x'PDk eosk)

Place$;EkB

Dated$fwsh

Verification$t?ohfce/PB

I hereby declare that the information given in above and attached documents is true and correct to the best of my knowledge and
belief and noting has been concealed therein. I know this fact very well that if any information given by me is found false the I shall
be liable for sentence under law and the benefits given to me on the basis of such information will be withdrawn summarily.

w?A fJZE/ fJj x';Dk eodk$eodh jK fe T[go'es fdZsh rJh ikDekoh ns/ Bkb BZEh d;skt/I w/oh ;wM nB[;ko ;jh tk do[Z;s j? ns/ fJ;
ftZu e[ZM th S[gkfJnk BjhA frnk j?.w?A fJBQK sZEK s'A ikD{ jK fe i/eo w/oh e'Jh th fdZsh rJh ;{uBK rbs fBebdh j? sK w?A ekB{zB ftZu
doi ;ik dk jZedko j'tKrk$j'tKrh ns/ w?B{z fJ; ;{uBk d/ nkXko s/ fdZs/ rJ/ bkG tkfg; b? bJ/ ikDr/.

Place$;EkB

Dated$fwsh

Self- Declarant (x'PDk eosk)

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 Declaration form for issuance of General Caste Certificate

nkw iksh dk ;oNhfce/N ikoh eoB ;pzXh fpnkB gq'ckowk

I solemnly declare that I _______________________ Son/Daughter/Wife of Shri____________________

R/o___________________________________ belong to___________ caste and permanent resident of Punjab, this certificate is
required to me/my minor boy/girl ______________

w?A_____________________g[Zso$g[Zsoh$gsBh;qh_____________________ tk;h _____________________ Xow Bkb fpnkB ehsk j?

fe w?A _____________________ iks Bkb ;pzX oZydk$oZydh jK.gzikp dk gZe/$gZeh s"o s/ t;Bhe jK ns/ fJj ;oNhfce/N w?B{z nkgD/
bJh _____________________ ukjhdk j?.

Deponent/fpnkB eosk

Declaration from Nambardar/Sarpanch/MC/fpnkB Bzpodko$;ogzu$n?wH;hH

I ____________________Nambardar/Sarpanch/MC. R/O___________________________solemnly declare that

______________________Son/Daughter/Wife of Shri_________________________

R/o___________________________ is permanent resident of the given address and I personally know the declare.

w?A______________ Bzpodko$;ogzu$n?wH;hHtk;h ______________ Xow Bkb fpnkB eodk$eodh ______________ jK fe

g[Zso$g[Zsoh$gsBh ;qh tk;h______________ dk gZe/$gZeh s"o s/ t;Bhe j? ns/ w?A fpnkB eosk B{z iksh s"o s/ ikDdk$ikDdh jK.

Signature of Nambardar/Sarpanch/M.C.$j;skyoL Bzpodko$;ogzu$n?wH;hH

__________________________________________________________________________________

Sr. No.$bVh Bzpo___________ Dated$fwsh

Report Concerned Patwari:$fog'oN jbek gNtkoh

Signature: Circle Patwari$j;skyojbek gNtkoh

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 dcso sfj;hbdko, ___________

Bzpo____________________ fwsh____________________

w[{b o{g ftZu ;/tk fty/ T[g wzvb w?fi;No/N______________ B{z G/i e/ p/Bsh ehsh iKdh j? fe gNtkoh jbek dh fog'oN ns/
;ogzu$Bzpodko$fwT{Af;gb e";bo dh s;dhe d/ nkXko s'A gqkoEh= _____________________ g[Zso$g[Zsoh$gsBh

;qh____________________tk;h____________________ sfj;hb____________________ fIbQk ________

B{z____________________ (iksh) dk ;oNhfce/N ikoh eoB dh f;ckfoP ehsh iKdh j?.

(sfj;hbdko)

___________________

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 Feed Back Form/ ਫੀਡਬੈਕ ਫਾਰਮ

1. Is there any unnecessary information being asked in the Form?/ ਕੀ

□ Yes / ਹ
eh ਫਾਰਮ ਿਵੱ ਚ ਕੋਈ ਵੀ ਬੇਲੋੜੀ ਜਾਣਕਾਰੀ ਮੰ ਗੀ ਗਈ ਹੈ <
□ No / ਨਹ

If Yes, Please specify the detail/ ਜੇਕਰ ਹ , sK ਵੇਰਵਾ fdT[

2. Is any vague information being asked in the form?/ ਕੀ ਫਾਰਮ ਿਵੱ ਚ eh

□ Yes / ਹ
eh ਕੋਈ ਵੀ ਅਸਪ ਟ ਜਾਣਕਾਰੀ ਮੰ ਗੀ ਗਈ ਹੈ <
□ No / ਨਹ

If Yes, Please specify the details/ ਜੇਕਰ ਹ , sK ਵੇਰਵਾ fdT[

3. Is the space provided in the form sufficient for filling up the

required information?/ ਕੀ ਫਾਰਮ ਿਵਚ ਮੁਹੱਈਆ EK b'VhAdh ਜਾਣਕਾਰੀ ਭਰਨ ਲਈ □ Yes / ਹ
ਕਾਫ਼ੀ ਹੈ □ No / ਨਹ

If No, Please specify the details/ ਜੇਕਰ ਨ , sK ਵੇਰਵਾ fdT[

4. Any other suggestion you may like to make, Please specify / ਕੋਈ ਹੋਰ ਸੁਝਾਅ ਦੇਣਾ ਚਾਹੁੰ ਦੇ ਹੋ ਤਾ ਵੇਰਵਾ fdT[

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