(DECLARATION BY THE APPLICANT BELONGING TO SCHEDULED CASTE CATEGORY)

Space for
Photograph
Managing Director,
Haryana State Industrial & Infrastructure
Development Corporation Ltd.,
C-13 & 14, Sector-6,
Panchkula (Haryana).

I, ______________S/D/W/o _____________________ R/o___________ do hereby

solemnly affirm and declare as under:-

1. I have applied to the Corporation for allotment of plot measuring ______ sq.
mtrs., located at Industrial Estate __________.

2. I belong to Scheduled Caste category and a certificate issued by the Competent

Authority in this regard shall be furnished to the Corporation.

Place: DEPONENT
Date: ( )

VERIFICATION:

I, the above named deponent do hereby solemnly affirm and declare that the
contents of my above mentioned declaration are true and correct to the best of my
knowledge and belief and nothing has been concealed therein. I further undertake that
in case the contents of this declaration are found to be false or misleading, the
Corporation shall be at liberty to initiate Civil or/and Criminal proceedings against me
and to take any action against me as deemed fit, including cancellation of
allotment/resumption of the plot/shed as well as recovery of any penalty/damages.

Place: DEPONENT
Date: ( )