FORMAT OF APPLICATION FOR CASTE & RESIDENCE CERTIFICATE APPEND REQUISITE DOCUMENTS WHERE NECESSARY To The Mandal Revenue Officer, ------------------------ Mandal ------------------------ District Sir, 1. Full Name of the applicant ----------------------- 2. Name of the Father/Husband/Guardian -------------------- 3. Age of the Applicant--------------Date of Birth-------- (if not known exactly give year of birth) 4. Complete address of the Applicant ----------------------- 5. Place of Birth of the Applicant ---- Village ---- Mandal ----- District 6. Place where applicant is ordinarily resident ---- Village --- Mandal ---- District. 7. Reason why applicant is residing in address mentioned in Col.6 above---------- 8. Present residential address and residing since how many years -------------- 9. If the applicant has previously obtained caste certificate details there of ( applicant to submit copy of the certificate previously obtained) 10. Details of Caste/Tribe/Backward class applied for ------------------ 11. Purpose for which certificate is required ----------------- 12. If caste/community status is recorded in any school certificate details there of (Copy of the same to be appended. DECLARATION I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief. In the event that any of the details are proved to be false I am liable for punishment under Sec.199 & 200 of the Indian Penal Code. Signature of the Applicant RECEIPT NO Sri -------------- S/o W/o D/o --------------------------------- of -----------------Village has submitted an application for Caste and Residence certificate and is received by this office on ---------------- date. The certificate will be issued within 15 days from this day failing which the applicant may represent before superior officer in this regard. Signature and designation of the person receiving the application AFFIDAVIT (On Rs. 10/- Non judicial stamp paper or affix Rs. 10/- special adhesive stamp) I -------------------------------------- S/o Sri ------------------------------- aged about --------------- years having an occupation of ---------------------, resident of ---------------------- do hereby solemnly affirm and state on oath as follows. I am the deponent herein as such I am well acquainted with the facts of this affidavit. I submit that I am the permanent resident of ----------------------------- -----------------------(give complete address) of ----------------- Mandal --------------- District. I submit that I belong to ------------------------- Scheduled Caste/Tribe/Backward class Group ---------- at Sl.No. ----------------which was assigned in the AP Gazette. I submit that I have an annual income of Rs. ---------------- from all sources. The said certificate of caste, residence and income is necessary for my son named----------------------------------------------. The above facts stated are true and correct to the best of my knowledge and belief. Hence this affidavit. Sworn and signed before me on this ---------------------day of ------------month -----------year at ( place) ------------------------. DEPONENT. NOTARY. ------------------------------------------------------------------------------------------------------------ (This format of affidavit is common for caste, residence & income certificates. The applicant needs to declare only the appropriate clauses. In case the application is for all the three certificates as above only one affidavit including all the three clauses will suffice)
