APPLICATION FORM FOR ISSUANCE OF SCHEDULE CASTE CERTIFICATE
(Fields marked * are mandatory)
Documents Required
Mandatory Documents
Paste
1. Proof of Identity of Applicant - Voter ID / Aadhaar Card / PAN Card / Passport.. etc * Applicant
Photo
Supporting Documents
1. Copy of final Published Settlement RoR / Consolidation RoR / Land Passbook
2. Self-Declaration / Recommendation from people's Representatives
3. Copy of Certificate issued in favour of Parents / sibling’s if any
4. Any other document in support/claim
Delivery Timeline
Estimated Timelines to Process the Application (Expected Date of Delivery) - 15 Working Days
(Expected date is calculated excluding holidays)
Fill all the details in the block letters
Personal Details
Applicant Name* :- ___________________ ___________________ ___________________
Gender* :- ____________________ Marital Status*:- ___________________
Date of Birth* :- ___________________ Age* :- ___________________
Aadhar Number :- ___________________ Religion :- ___________________
Phone No :- ____________________ Mobile No:- ___________________
Email Id :- _________________________________________________
Parent’s Details
Father Name* :- ___________________ ___________________ ___________________
Mother Name* :- ___________________ ___________________ __________________
Permanent Address :- o Urban o Rural
Applicant residing outside Odisha? If Yes -
State* :- ____________________
District * :- ___________________ Sub Division * :- ____________________
Tahsil * :- ___________________ RI Circle * :- __________________
Village * :- ____________________ GP /ULB :- ___________________
House no. / Street Name :- ___________________ Police Station * :- __________________
Post Office :- ___________________ Pin :- __________________
Family Members / Guardian Details (In case of minor or person unable to manage his/her own affairs):
If any other person other than applicant filling the Application? * o Yes o No
Relation With Applicant* :- _______________________________________
Submitter's Name* :- ___________________ ___________________ ___________________
Present Address :- o Urban o Rural
Is Present Address Same as Permanent Address? o Yes o No
(If "No" please fill the Present address given below)
State * :- ____________________
District * :- ___________________ Sub Division * :- ____________________
Tahsil * :- ___________________ RI Circle * :- __________________
Village * :- ____________________ GP /ULB :- ___________________
House no. / Street Name :- ___________________ Police Station * :- __________________
Post Office :- ___________________ Pin :- __________________
Parents/Father's Address
Parents/Father's Address (Married woman-in case of inter caste marriage) o Yes o No
(If "Yes" please fill the Present address given below)
State * :- ____________________
District * :- ___________________ Sub Division * :- ____________________
Tahsil * :- ___________________ RI Circle * :- __________________
Village * :- ____________________ GP /ULB :- ___________________
House no. / Street Name :- ___________________ Police Station * :- __________________
Post Office :- ___________________ Pin :- __________________
Land Record Details
Is RoR Produce :- o Yes o No
(If "Yes" please fill the Present address given below)
District * :- ___________________ Sub Division * :- ____________________
Tahsil * :- ___________________ RI Circle * :- __________________
Police Station :- ____________________ Mauza(Revenue Village) :- ___________________
Khata No* :- ___________________ Recorded Tenant Land Owner :- __________________
Registered Sale Deed No. :- ________________ Registered Sale Deed Date :- __________________
Relation of the Applicant with the Land Owner :- ________________________
Caste Details
Caste* :- ________________ Religion* :- _________________
Purpose :- _____________________________________________________________________________
Declaration
I do hereby declare that the information given by me in this application form is true to the best of my knowledge and I
have suppressed / misrepresented any fact. That, I am solely responsible for the accuracy of the declaration and information
furnished and shall be liable for the action under section 199, 200 and 420 of Indian Penal Code and other relevant laws / rules in
case of furnishing wrong declaration and information. Also, I am well aware of the fact that the certificate shall be summarily
cancelled and all the benefits availed by me shall be summarily withdrawn in case of furnishing wrong declaration and
information.
I Agree :- _____________________ Place:-________________________
