To

The Mandal Revenue Officer/
Revenue Divisional Officer/
Sub-Collector/Assistant Collector/
District Collector.

..........................Mandal/Division

.......................District

Sir,

I am in need of a Scheduled Caste/Backward Class community certifi-
cate for me/ for my son/ daughter for which the details are given below:

1. Name of the applicant in full (in block letters)

2. Sex of the applicant

3. a) Father's name
b) Mother's name

4. Present postal address

5. Permanent place of residence

6. Age, date of birth and place of birth (If date is
not known approximate year on birth)

7. Place of ordinary residence (documents relating
to house/land or other immovable property or
birth registration certificate or ration card or
school records may be furnished).

8. If the applicant has been issued a community
certificate in the past by any authority, a copy
of such certificate should be furnished.

9. Community for which certificate is claimed
(including sub-caste)

10. a) Caste (including sub-caste) of the father
b) Caste (including sub-caste) of the mother

11. Religion professed by the applicant

12. a) Religion professed by the father of the applicant
b} Religion professed by the mother of the applicant

13. Whether the applicant is

a) a natural born son or daughter of his/her parents

OR

b) adopted son/daughter of his/her parents

DECLARATION

I/We declare that the information furnished by me/us in the application is true
arxi correct, and the documents appended thereto are genuine and the con-
tents of the documents are true and correct and that rf these are found to be
untrue and incorrect, I/We will be liable for prosecution for furnishing false and
incorrect information/ documents under Section 10 of the Act No. 16 of 1993.

STATION Signature of the applicant

Signature of the Parent/Guardian

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