SELF DECLARATION FOR APPLY Certify Copy / Income/ Resident / Caste / SEBC / OBC / Legal heir / Solvency / Income & Assets (EWS) certificate

 

SELF-DECLARATION

1. I am Sri/Smt./Miss. _____________________________ Son/Wife/Daughter of ____________________________ Sex-Male/Female/Transgender, Marital Status: Married/ Unmarried/ Widow/ Widower, Age _______ years, declare that, my present address is At. ______________________________________________________________, P.O-___________________________________, P.S: Saintala, Dist.: Balangir,,PIN- __________________ Odisha.

2. That my Permanent Address/Parental Address is: C/o- _______________________________________________, At. ___________________________, P.O.: ___________________________, P.S.: __________________________, Tahasil: ____________________, Dist.: ___________________, PIN: ______________, State: ______________

(It is Compulsory to mention the Parental Address in case of married women applying for Caste certificate)

3. That Sri/Smt./Miss. _____________________________ Son/Wife/Daughter of __________________________ the recorded tenant/Co-tenant of M.S Khata No. __________________ of Mouza: ________________________, under RI Circle: _______________________, under Tahasil: ______________________, Dist: ______________________, is my _________________________________, (In-case of married woman applying for SEBC/OBC certificate mention the land details of ROR of Paternal-side if any)

4. That out of the above M.S khata No. __________________ Total Area Acre: __________________ my/my father's/mother's share is Acre __________________ only. (Compulsorily· mention share of land in case of Income, SEBC, OBC and Income & Assets certificate)

Genealogy Linking the RT with the applicant

 

 

(Full Signature of the Applicant/Minor)                        (Full Signature of the Legal Guardian/Parents)·

 

5. That I am a landless person and I/my family/forefather do not have any recorded landed property/ROR.                 (Please strike out if not applicable)

6. That my total Annual Family Income from all known sources is Rs. ____________________ (Out of which income from Agriculture Rs. ________________, from Business Rs. ________________, from Salary Rs. ________________ & from Other Sources (namely ________________________) Rs. ________________,

7. That, I belong to  ________________ by Caste and  ________________ by religion which comes under Scheduled Tribe/Scheduled Caste/SEBC/OBC Category. (Please strike out which is not applicable)

8. That, I have no land/Landed property in urban area except in village  ________________________,  and no one from my family is serving as Group-A or Group-B Civil Servants or equivalent posts in Central Govt. /Sate Govt. /PSUs etc. (Applicable only for applicants applying for SEBC/OBC certificate)

9. That,

(i) Sri/Smt. ___________________________ & Sri/Smt. ___________________________are one and same person. (ii) Sri/Smt. ___________________________ & Sri/Smt. ___________________________are one and same person. (iii) Sri/Smt. ___________________________ & Sri/Smt. ___________________________are one and same person.

10. That (1) Sri/Smt./Kumari ___________________________ (2) Sri/Smt/Kumari ___________________________ don't have any ID proof such as Voter Card/AADHAAR Card and that's why I have submitted Local MLA, Sarpanch recommendation letter, Recommendation letter from Head of School/College last attended with photograph attested etc.

11. That I am submitting this declaration in order to obtain, Certify Copy / Income/ Resident / Caste / SEBC / OBC / Legal heir / Solvency / Income & Assets (EWS) certificate from the Tahasildar, Saintala for the purpose of Education / Service / Medical Treatment Assistance from the Govt. / Other purpose namely _______________________________ of myself /my family.

12. That I am submitting the minimum necessary supporting documents (Self-attested) against the declaration given above.

                        I declare that the above information furnished by me, my minor son/daughter in this application form and its self-attested enclosures are true to the best of my knowledge and belief and the information furnished is exhaustive and nothing has been suppressed. I am solely responsible for the accuracy of the above declaration and information furnished and shall be liable for action under Section-199,200 & 420 of the Indian Penal Code in case of any wrong declaration and information. Also, I am well aware that the Certificate issued shall be summarily 'Cancelled and all the benefits availed by me / my son / my daughter through the certificate shall be summarily withdrawn in case of any wrong declaration and information.

 

Place:                                                                                       Full Signature of the Applicant

 

Date:                                               Full Signature Legal Guardian, Parents (in case the applicant is a minor)

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