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(Anneyure to c.O.Ms.No.5, Schedutel, Castes D€velopment (POA.A2)
Deoart-ent, dated 08.08.20,j.,
-
Form ofAppllcatton for i6sue of Communftj, and Date oi Blrth Ce*ificate retaflng to
Scheduled TrtbB6 un.ter Secri,on 3 (,1) and 3 (2) ofthe Act 16 of 1S93

fl.rform;tlor ro be iLrn:qi.o by' ihe :Dst.c:ot hlmsef suoooneo Dy rhE docLnenter)

To
The firandal i{evenue Officer /
Revenue Divislonal Ofrlcer /
Sub-Co.lecto,, asst. Cor..to.
.'-,----,- i\4andal/ DMsion.
- - -------- -..---District
5l-
I am in need of a Scheduled Tribes Commonib/ and Daie of Bidh Certifteate fdr Rie /for llry
Deugl'te. for W.Jch tne oeta rs are g,ver Derow:

1. Name ollhe Appllcant in

2. Sex of the Appttcant
fut (ln Btock Letterc)
hLi
3, a) Fathert Narne
b) iiolheas Name
4, Present Postal adaress
5, Place ofpennanent restdence of the ceruflcate
seeker/ hjs faiher/ paternal orandtuther, as on
the date or the irsl noiiftcatlon declaring the
communlty as a s.heduled _Tnbe, to
6)
6, Age, Date of Blrth anci Place of Btrth (lf date ls
not known apFrox, Year of Btrth)
7. Place of ordinary Resldence Documents related
to house/Land or other tmmovable propedy or
Bith Reqlstrction Ceriifl.atcs or Ratlon CarC or
Schoo records rnay be aurnished
8. 1fthe applicani has been tssued E commlrntty
Ce.U6(ate Intb€ past by any authortty, a copy
Of su.h Certlficste should be furnJshen.
9. Community for whlch certiflcate t;.laimed
(lncludlnq Tdbe, 5ub-Group)
10. (a) Communlty ofihe rather
8lo8*Sg{{(,.
(Including 5ub-!nbs or 6ub qr.(p)
(b), CommLrnlty ol the mrther
(Includlng sub-trlbe or sub grolip)
C rv.4-cl
,11, Wheiher the appltcant is
(a) A natural born son o. dairghter of hls/her
Darents, oR
{b) adopled son/daushter of hts/her pareRts

12. Aadhaar Number

13. Household Surv€y No

DECLARATION

l/we dealare that the lniormatian the appli.atloi ls true and

Corr€ct, and ih€ d.cLrme ls apFended ne and the conlerls oi lhe
D.cuments are true anc .nmect.nd thal Lo be Lrnirue and incorred, I/We
WiiT be llable for ptusEcutlon ror lumishjnq lncorrect lnfonnaiion d!auments under
Section 10 ofthe Act N0.16 of 1993.

Sidtion:
f.eSo^u'
S gnature of the Appllcant.
Date i

Slgnature of the Parenvcuardlan

Erclas]JriE:
1- APPIICEIIAN FO'M *{ NOT MANDATORY rcR GITIZEN IOGIN )
2. Communii/ CeftincEle lssued to the famlly members*
3. 55C sarls m.Fo orDOE ettEctorTrensf,scsnlkste+
4, 1TO 1Or1 ltlidt ertifri:ir o. Do6 cerlnE tes rssJed lry MiJriclpellLy/Gl-.m Pa!{ln_ath *
5. qauln car!,/EPIc G.d /A DH R alRD*
5. D,rnim.nts related tc iam.€be Pmperds#

(+-mandatory ir-any cne of them)