ANNEXURE-V. Form for Community, Nativity and Date of Birth Certificate Serial No. S.C. District Code: S.T. Emblem Mandal Code : B.C. Village Code : Certificate No: COMMUNITY, NATIVITY AND DATE OF BIRTH CERTIFICATE (1) This is to certify that Sri/Smt./Kum. _____________________ Son/Daughter of Sri ___________________ of Village/Town ______________ Mandal ____________ District _______________ of the State of Andhra Pradesh belongs to ___________ Community which is recognised as (*) S.C./S.T./B.C. under: The Constitution (Scheduled Castes) Order, 1950 The Constitution (Schedule Tribes) Order, 1950 G.O.Ms.No:1793, Education, dated:25.9.1970 as amended from time to time (BCs.) S.Cs., S.Ts. list (modification) Order, 1956 S.Cs. and S.Ts. (Amendment) Act, 1976. (2) It is certified that Sri/Smt./Kum. ________ is a native of ________ Village/Town ________ Mandal ________ District of Andhra Pradesh. (3) It is certified that the place of birth of Sri/Smt./Kum. _______________ is ___________ Village/Town _________ Mandal __________ District of Andhra Pradesh. (4) It is certified that the date of birth of Sri/Smt./Kum. _______________ is ____________ Day ______ Month ___ Year ______ (in words) __________________ as per the declaration given by his/her father/mother/guardian and as entered in the school records where he/she studies. Signature: Date: Name in Capital Letters: Designation: (seal) Explanatory Note:-While mentioning the community, the Competent Authority must mention the sub-caste (in case of Scheduled Castes) and sub-tribe or sub-group (in case of Scheduled Tribes) as listed out in the S.Cs. and S.Ts. (Amendment) Act, 1976.
