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Self Declaration Form

The document is a self-declaration by Swarna Shree Sahu, affirming the truthfulness of the information provided in her application for a certificate under the Odisha Miscellaneous Certificate Rules, 1984. She declares her caste as Rangani, sub-caste OBC, and states her occupational background as weaving, with the purpose of the declaration being for educational purposes. The applicant acknowledges responsibility for the accuracy of the declaration and the consequences of any false information.

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Sridhar Panigrahi
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1K views1 page

Self Declaration Form

The document is a self-declaration by Swarna Shree Sahu, affirming the truthfulness of the information provided in her application for a certificate under the Odisha Miscellaneous Certificate Rules, 1984. She declares her caste as Rangani, sub-caste OBC, and states her occupational background as weaving, with the purpose of the declaration being for educational purposes. The applicant acknowledges responsibility for the accuracy of the declaration and the consequences of any false information.

Uploaded by

Sridhar Panigrahi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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SELF DECLARATION

(AS PER ODISHA MISCELLANEOUS CERTIFICATE RULES,1984)

I SRI/SMT/MISS SWARNA SHREE SAHU AGED ABOUT 19 YEARS / DOB 2005-11-19, S/O, D/O,
W/O MANGALA CHARAN SAHU OF RATNAMANIPUR, VILLAGE SINGIPUR, PS-PATTAPUR, DIST-
GANJAM, ODISHA DO HEREBY DECLARE THAT THE INFORMATION GIVEN BY ME IN THIS
APPLICATION FORM AND ITS SELF-ATTESTED ENCLOSURE IS TRUE TO THE BEST OF MY
KNOWLEDGE AND THE INFORMATION FURNISHED IS EXHAUSTIVE AND I HAVE NOT
SUPPRESSED ANY FACT. THAT I SOLELY RESPONSIBLE FOR THE ACCURACY OF THE
DECLARATION INFORMATION FURNISHED AND LIABLE FOR ACTION UNDER SECTION 199
AND 200 OF THE INDIAN PENAL CODE IN CASE OF 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WITHDRAWN IN CASE OF WRONG DECLARATION AND INFORMATION.

CASTE DETAILS:

RELIGION: HINDU

CASTE: RANGANI

SUB CASTE / COMMUNITY: OBC

OCCUPATIONAL BACKGROUND: WEAVING

PURPOSE: EDUCATIONAL PURPOSE

SIGNATURE OF THE APPLICANT

DATE: 10-07-2025

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