REVENUE DEPARTMENT GOVT OF NCT OF DELHI ......1 REVENUE DEPARTMENT, GOVT.OF NCT OF DELHI APPLICATION...

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1 REVENUE DEPARTMENT, GOVT. OF NCT OF DELHI APPLICATION FORM SC/ST CERTIFICATE BENEFICIARY DETAILS 1. e-DistrictRegistration Number : (For already Registered User- Not to be filled in by first time Applicants or those having Aadhaar number) OR 2. UID (AADHAAR) No : 3. Name of Beneficiary : ___________________________________________ 4. Name of Father : ___________________________________________ 5. Name of Mother : ___________________________________________ 6. Name of Spouse : ___________________________________________ 7. Gender : Male Female Other 8. Date of Birth (DDMMYYYY) : 9. Mobile No. : e-Mail ID :_________________@___________ (in case of minor, provide parents contact details) 10. Present Address (Address of Parents in case of Minor ) House Name/No : ______________________ Locality : ______________________ Sub- division : ______________________ State : ______________________ PIN Code : Sub-Locality : ______________________ Village/Town : ______________________ District : ______________________ Country : _______________________ 11. Whether the Present and Permanent Address is same : Yes No 12. If No, Permanent Address (Address of Parents in case of Minor) House Name/No : ______________________ Locality : ______________________ Sub- division : ______________________ State : ______________________ PIN Code : Sub-Locality : ______________________ Village/Town : ______________________ District : ______________________ Country : _______________________ DETAILS REQUIRED FOR ISSUANCE OF SC/ST CERTIFICATE 13. Applying for : Scheduled Caste Scheduled Tribe 14. Whether any SC/ST certificate has been issued to any of the relatives from the paternal side? Yes No (If the answer to the above question is ‘No’ please go directly to S.No. 18.) 15. For SC/ST certificate mentioned in S.NO. 14 a. Issued to : _____________________________ b. S.No. of the certificate: ______________________________ c. Date of Issuance of certificate: __________________________ d. Designation of the Issuing authority: ________________________ e. Relationship of the applicant with the certificate holder: _____________________ ( a copy of the self-attested certificate should be attached) Beneficiary color Passport Size Photograph Size – 5 x 4.5 (Cm.) Or 2 x 1.75 (Inch)

Transcript of REVENUE DEPARTMENT GOVT OF NCT OF DELHI ......1 REVENUE DEPARTMENT, GOVT.OF NCT OF DELHI APPLICATION...

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REVENUE DEPARTMENT, GOVT. OF NCT OF DELHI

APPLICATION FORM – SC/ST CERTIFICATE

BENEFICIARY DETAILS

1. e-DistrictRegistration Number :

(For already Registered User- Not to be filled in by first time Applicants or those having Aadhaar number)

OR

2. UID (AADHAAR) No :

3. Name of Beneficiary : ___________________________________________

4. Name of Father : ___________________________________________

5. Name of Mother : ___________________________________________

6. Name of Spouse : ___________________________________________

7. Gender : Male Female Other

8. Date of Birth (DDMMYYYY) :

9. Mobile No. : e-Mail ID :_________________@___________

(in case of minor, provide parents contact details)

10. Present Address (Address of Parents in case of Minor )

House Name/No : ______________________

Locality : ______________________

Sub- division : ______________________

State : ______________________

PIN Code :

Sub-Locality : ______________________

Village/Town : ______________________

District : ______________________

Country : _______________________

11. Whether the Present and Permanent Address is same : Yes No

12. If No, Permanent Address (Address of Parents in case of Minor)

House Name/No : ______________________

Locality : ______________________

Sub- division : ______________________

State : ______________________

PIN Code :

Sub-Locality : ______________________

Village/Town : ______________________

District : ______________________

Country : _______________________

DETAILS REQUIRED FOR ISSUANCE OF SC/ST CERTIFICATE

13. Applying for : Scheduled Caste Scheduled Tribe

14. Whether any SC/ST certificate has been issued to any of the relatives from the paternal side? Yes No

(If the answer to the above question is ‘No’ please go directly to S.No. 18.)

15. For SC/ST certificate mentioned in S.NO. 14

a. Issued to : _____________________________

b. S.No. of the certificate: ______________________________

c. Date of Issuance of certificate: __________________________

d. Designation of the Issuing authority: ________________________

e. Relationship of the applicant with the certificate holder: _____________________

( a copy of the self-attested certificate should be attached)

Beneficiary color Passport Size

Photograph

Size – 5 x 4.5 (Cm.)

Or

2 x 1.75 (Inch)

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16. Proof of Relationship of proposed beneficiary with the certificate holder as mentioned in S.No.15 (Attach Copy)

Aadhaar card Passport Birth Certificate

Voter ID Card Ration Card Any Government ID containing

names of both the beneficiary

and certificate holder as family

member

Driving License PAN Card

Document No :

17. Please select any one applicable category out of a, b or c below:

a. Family is original Inhabitant of Delhi since prior to 1951 and your caste is notified as SC in Delhi

i. Name of Caste: ___________________

ii. S.No. of the caste in notification for Delhi: _________________________

b. Family has migrated to Delhi after 1951 but settled/ domiciled in Delhi and your caste is

notified as SC/ST from your state of migration as well as in Delhi( not valid for ST)

i. Name of the caste: ________________

ii. S.No. of the caste in notification for Delhi: ______________________

iii. Name of the State from which migrated: ______________________

iv. S.No. of the caste in the list in the state of origin:________________

v. Attach self-attested photocopy of at least one of the following documents:

Birth Certificate proving applicant was born in Delhi

Matriculation certificate/ mark sheet of a Delhi School for the applicant

Any proof of residence in Delhi since last 5 years

c. Family Migrated to Delhi after 1951 but caste is not notified as SC in Delhi

i. Name of caste: _______________________

ii. State from which migrated:__________________

iii. S.No. of the caste in the list in the state of origin______________________

18. If you have filled S.No. 15, 16 and 17 go directly to S.No. 19, then do not fill this column

When no Certificate has been issued to any of the paternal relatives, field verification shall be conducted to

ascertain case status. Please select one of the following:

a. For Original Delhi residents

I. Name of the caste:_____________________

II. S.No. of the caste in notification for Delhi:___________________

III. Proof of Stay in Delhi prior to 1951:_______________________

b. For Migrant Population

I. Name of the caste:_____________________

II. S.No. of the caste in notification for Delhi :___________________

III. State from which Migrated:_______________________________

IV. S.No. of the caste in the State of origin:_____________________

V. Proof of stay in state of origin prior to 1951

VI. Attach Self attested copy of atleast one of the following documents:

Birth Certificate proving applicant was born in Delhi

Matriculation certificate/ mark sheet of a Delhi School for the applicant

Any proof of residence in Delhi since last 5 years

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19. No certificate will be issued to an applicant who is migrant to Delhi and caste doesnot fall in Delhi State list and

no caste certificate has ever been issed to a paternal relative.

20. Purpose of obtaining Certificate :_______________________________________________________________

21. Religion (In case of SC) Hindu Sikh Buddhist

Date:

Signature of Beneficiary :

(Parents Signature in case of minor) Place: ______________________

DD MM 20YY

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22. Self-Declaration

I ________________________________________S/o/D/o Sh._______________________________

aged _______________R/o____________________________________________________________

Verify as Under:

I. That the above contents are correct to the best of my knowledge and belief and nothing has been concealed

therein.

I further affirm that-

II. I am aware that in case the information furnished above is found to be incorrect, I shall be liable for prosecution

under section 177 & 191 of the Indian Penal Code, which stipulates as under:-

177. Furnishing False Information- whoever, being legally bound to furnish information on any subject to any

public servant, as such, furnishes, as true, information on the subject which he knows or has a reason to believe

to be false, shall be punished with simple imprisonment for a term which may extend to six months, or fine which

may extend to one thousand rupees, or with both;

Or, if the information which he is legally bound to give respects the commission of an offence, or is required for

the purpose of preventing the commission of an offence, or in order to the apprehension of an offender, with

imprisonment of either description for a term which may extend to two years, or with fine, or with both.

191. Giving false evidence- Whoever being legally bound by an oath or by an express provision of law to state

the truth, or being bound by law to make a declaration upon any subject, makes any statement which is false,

and which he either knows or believes to be false or does not believe to be true, is said to give false evidence.

III. Providing any false evidance shall be punishable under section 193 of IPC, 1860 which provides imprisonment

for a term upto three years and fine.

Date:

Signature of Beneficiary :

(Parents Signature in case of minor) Place: ______________________

DD MM 20YY