Court Fee Stamp as required APPLICATION FORM FOR ISSUANCE OF

SOCIALLY AND EDUCATIONALLY BACKWORD CASTE CERTIFICATE

(Fields marked * are mandatory) Paste Applicant

Service Payment Details : Photo
1.Service Charges of the kiosk Operator per Unit = 18.00
2.Printing Charges per unit = 10.00
3.Scanning Charges per unit = 5.00
4.The Government fees per unit = 30.00
5.Degs Charges fee per unit = 2.00
(The amount may vary based on no of printing and scaning page counts)
The Acknowledgement of receipt of Application / Delivery of Certificate and
Payments received from the citizens shall be issued free of cost by the CSC operator to the citizens.

Documents Required Applicant’s signatutre

Mandatory Documents
Supporting Documents 1. RoR
2. Self Declaration
3. Land Pass Book
4. Any other document in support/claim
Delivery Time Lines ; Estimated Timelines To Process The Application (Expected Date of Delivery) :

Fill all the details in the block letters

Personal Details
Applicant Name* :- ___________________ ___________________ ___________________
Gender* :- ___________________ Marital Status*:- ___________________
Date of Birth* :- ___________________ Age* :- ___________________
Parents Details
Father Name* :- ___________________ ___________________ ___________________
Mother Name*
:- ___________________ ___________________ _______________
Spouse Details
Spouse Name* :- ___________________ ___________________ ___________________
Relation With Applicant* :- ___________________
Contact Details
Phone No :- ___________________ Mobile No :- __________________
Email :- ___________________

Permanent Address :- Urban Rural

District * :- ___________________ Sub Division * :- __________________
Tahsil * :- ___________________ RI Circle * :- __________________
Block * :- ___________________ Village/Ward * :- ____________________________________________
House No/Name* :- ___________________ Police Station * :- __________________
Post Office * :- __________________
Pin * :- __________________
Submitter Details
Is applicant and submitter are same? * Yes No
Submitter's Name* :- ___________________ ___________________ ___________________
Relation With Applicant* :- _______________________________________
 Present Address :- Urban Rural

Is Present Address Same as Permanent Address? Yes No

(If "No" please fill the Present address given below)

District * :- ___________________ Sub Division * :- __________________

Tahsil * :- ___________________ RI Circle * :- __________________
Block * :- ___________________ Village/Ward * :- ____________________________________________
House No/Name* :- ___________________ Police Station * :- __________________
Post Office * :- __________________
Pin * :- __________________

Caste Details :-
Caste * :-__________________________________ Religion* _____________________________________
Sub Caste/Community :- _________________________________ Occupational Background :________________________
Serial number of the Caste in the State list of SEBC:- ____________

Purpose :- ___________________________________________________________________________________

Father Mother& Spouse Other Details

P l e as e se l e ct th e r e sp e cti v e r e la t io n ( Fa th e r / Mo th e r/ S p ou s e ) to fi l l up th e d e ta il s

State of the Parent (s)/Husband ,Fateher,Mother&Spouse:-

Father Mother Spouse

Constitutional Post:
Designation : _________________ _______________ ________________
Government Servic
Service(Central/State):

Designation: __________________ ________________ ___________________

Scale of Pay, including classification if any __________________ _________________ ___________________

Date of appointment to the Post: __________________ __________________ __________________

Age at the time of promotion to the class-1post: ___________________ __________________ ___________________

Employment of International Organization

Name of Organization: __________________ ___________________ __________________

Designation: ___________________ ___________________ _________________

Period of Service Form: ___________________ ___________________ _________________

Period of Service To; _______________ _____________________ ___________________

Death/Permanent In-capacitation (Putting an officer out of Service):

Date of Death/Permanent In-capacitation: __________________ ___________________ ____________________

Details of permanent In-capacitation; ____________________ __________________ ___________________

Employment in public Sector Undertaking

Name of organization; _____________________ __________________ ____________________

Designation: _____________________ ___________________ ___________________

Date of appointment to the post: ____________________ ____________________ ___________________

Armed Forces including Para-military forces

Designation: _____________________ ___________________ ____________________

Scale of pay; ______________________ ___________________ ___________________

Professional Class(Please indicate whether engaged in Trade, Business and Industry)

Applicant’s Occupation/Profession: _____________________ _____________________ __________________

Property Owners

Agricultural land holding (owned by mother, father and minor children)

Location: _______________________ _____________________ __________________

Size of holding (Area): _______________________ ______________________ _________________

Irrigated (type of Irrigated Land)

I _____________________ _______________________ ___________________

II _____________________ _______________________ ___________________

III ______________________ ______________________ ___________________

Unirrigated

IV. Percentage of irrigated landholding to statutory ceiling limit

Under state land ceiling law: ______________________ ________________________ __________________

V. If land holding is both irrigated/un-irrigated total irrigated land

holding on the basis of conversion formula under state land celing law:________________ _________________ ________________

VI. Percentage of total irrigated land holding to statutory ceiling limits as per (V):____________ ______________ _______________

Plantation

Crops/Fruits: ______________________ ______________________ ____________________

Location: ______________________ ______________________ ____________________

Area of Plantation: ______________________ ______________________ ____________________

Vacant land and buildings in Urban areas or Urban Agglomeration

Location of property: _____________________ _______________________ _____________________

Details of property: ______________________ _____________________ ______________________

Use to which it is put: _______________________ ____________________ ______________________

Income /Wealth

Annual family income from all Sources (including salaries &

Income from agriculture land): _______________________ _________________________ __________________

Whether Tax Payer (if yes, a copy of the last 3 returns be furnished):__________________ ____________________ _______________

Whether covered in wealth tax act(if yes,Furnish details): ________________________ _____________________ ________________

Wealth Tax Details: ________________________ _____________________ __________________

Any other remarks; _________________________________________________________________

I, Shri / Smt …………………………………………………..………..Son of / Daughter of / Wife of …………………………………………………………….

resident of village ……………………………………..…. P.S. …………..…………………… District ……………………..……. and I certify that the above said
particulars are true to the best of my knowledge and belief that I do not belong to the Creamy Layer of S.E.B.C/O.B.Cs. and eligible to
be considered for the posts reserved for S.E.B.C/O.B.Cs. In the event of any information being found false or incorrect, or ineligibility
being detected before or after the selection, I understand that my candidature/appointment is liable to be cancelled and I shall be
liable to such further actions as may be provided under the law and/or rules.

Yes No

Signature of the applicant

 ଲି ଖତ
ି ବୟାନ
ଏଥିଦ୍ଵାରା ଆମ୍ବେ ___________________________ ଗ୍ରାମର ଗ୍ରାମବାସୀ
______________________ ରାଜସ୍ୱ ନିରକ୍ଷକଙ୍କୁ ମ୍ବଲଖିମ୍ବେବା ବୟାନ ଏହିକି ମ୍ବେ, ଆମ୍ଭ ଗ୍ରାମର
ଶ୍ରୀ/ଶ୍ରୀମତି ______________________ ପିତା/ସ୍ୱାମୀ ______________________________ ବୟସ
_______ ବର୍ଷ, ଗ୍ରାମ __________________ ମ୍ବପାଷ୍ଟ ____________________ ଓ ଜିଲ୍ଲା –
ଗଞ୍ଜାମର ଜମ୍ବେ ସ୍ଥାୟୀ ଅଟନ୍ତି । ମ୍ବସ ଜାତିମ୍ବର _____________________ ଅଟନ୍ତି ଓ ହିନ୍ଦୁ
ଧମଷାବଲେି ଅଟନ୍ତି । ଏହା ଆମ୍ବେ ଜାେିଶେ
ୁ ି ମ୍ବଲଖାଇ ମ୍ବେଲୁ ମ୍ବେ, ତାଙ୍କ ପରି ବାର ଏଠାମ୍ବର
େୀର୍ଷ େିନ େିନ ମ୍ବହଲା ରହି ଆସୁଛନ୍ତି । ତାଙ୍କ ପରି ବାର ____________________________
ବାବେକୁ ବାର୍ିକଆୟ ଟ. ________________ ଙ୍କ। ଏେୁ ୋଖସ୍ତକାରୀ
__________________________ ପି/ସ୍ୱ।______________________________ ଙ୍କୁ
________________________ ଗ୍ରାମର ବାସସ୍ଥାନ, ଜାତିଗତ ପ୍ରମାେ ପାତ୍ର, ଚାକିରି, ଉଛଶିକ୍ଷା
ପାଇ ଁ େିଆଗମ୍ବଲ, ମ୍ବସଥିମ୍ବର କିଛି ଦ୍ଵିମତ ନ।ହି ଁ।

ଉପମ୍ବରାକ୍ତ ବୟାନ ପାତ୍ର ସମ୍ପୂର୍ଣ୍ଷ ଜ୍ଞାନମ୍ବର ମ୍ବଲଖାଇ ମ୍ବେଲୁ ମ୍ବେ, ଆବଶୟକ ମ୍ବବମ୍ବେ
ସରକାରୀ କାେଷୟମ୍ବର ଆସିବ ।

ସରପଞ୍ଚଙ୍କ ସ୍ଵାକ୍ଷର ଗ୍ରାମବାସୀଙ୍କ ସ୍ଵାକ୍ଷର

୧.

୨.

୩.

୪.

୫.

ରାଜସ୍ୱ ନିରକ୍ଷଙ୍କ ସ୍ୱାକ୍ଷର