it l-'ee Stamp as required

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APPLICATION FORM FOR ISSUANCE OF CASTE CERTTFICATE

{['
Fields marked * are mandator).) '3!r
I
Sen,ice Payment Details :
l.Service Charges ofthe kiosk Operztor = B
t8.00
2.Printing Charges per unit ..
r0.00
i.Scanning Charges per unil =
5.00
:l.Degs Charges fee =
2.00
( l}e anrount may vary based on uo ofprinting and scaring
page counts) 't^rr.rh ll*"*!J1
1-he Acknowledgenrent of receipt ofApplication / Delivery
ofCerlificate and
Pavments received fro, the citizens shal be issued free ofcost by the csc operaor to the citizens
Documents Required
Applicant's signatutre
Mandatorl D ocuments
Sun Dortins Documents
l.RoR_
2.Land pass Book.
from sarpanch/ MLA/ Mp
i:ff.",m.aj#ron
5 Any other document in support/claim
I)eliverv Time Lines ; Estimared r-ir.nerines To process The
Apprrcation (Expected Date of Delivery) :

Fill all the details in the block letters

Pcrsonal Details
Applicant Narnet
(iender'*
M ital Status*:-
Date of Birth* Age* :-
Parents Details
Father Name* 9W*
\4other Name* SUK+NTI
Spouse Details
Spouse Name*
Relation With Applicant*
Contact Details
Phone No :- . \o
Mobile V6oo Wz-
F.mail
Pcrmanent Address
=k *. { tt -zx( tSn G_s*lo &-, ia
House No/Name*
District *
Vllage / Town+:- NU +htr*+- r4
Sub Division *
'lahsil *
RI Circle *
Block * L Police Station *
Post Oflice +
Pin *
Submitter Details
Is applicant and submitter are same? * Yes No
Submitter's Name*
Relation With Applicant*
Purpose *
,>.
 Present Address
Is Present Address Same as Permanent Address? y"r&G
(lf "No" please fill the Prcsent address given below)
House No,tlame+ Mlluge *'-
District + Sub Division *
.lhhsil +
RI Circle +

B lock * Police Station +

Post Office * Pin *

[,and Record Details
Is ROR Produced? Y.rV No
(ll"YES' please pr.ovide the LandRecord Details)
-
District* rr' U Sub Division *
Tahsil * Ll RI Circle *
Police Station *

Khata No * q1, ft Mouza(Revenue Village) *

Recorded Tenant (Land Owner)
_wwaa1
)
Rclation of LJte applicant wirlr Recorded f
Tenant s :- \Sl
Plot Details

s IN Plot No * Kis.m *
I
L

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Caste Details Caste Tribe
(lf Caste is selected ,please provide
these details)
Castc "
(lfTribe is selected,please provide these
1\ Sub Caste/Comm unity* t 4J\'14-l
details)
Tribe " SubTribe*:-

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nowlejge and beliefand that they are exhaustive and I have not suppressed any fact. In case
it is detected later on that any ofthe fhct
(ted herein wrong or that I have suppressed some material facts, I shall be liable for prosecution
under the relevant law.

faa*'\ 4"-"1.4
Signatule of the applicant.
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Enrollment No. : 1088n23O2100374
Note Children on attaining 5 years oF age
To need to provide biometric informatiun
Tarush Hansdah

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S/O: Salkhan Hansdah Ii\JFLTRil4ATION
Nuhamalia
Kakharusole,Chandua,ilayulbhani,
s AaChailr is proof of identity, not of citizenship
Odisha - 757014
B To establish identity, authenticate
online.

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Tarash Hansdah
Address: S/O: Salkhan Hansdah,
Father: Salkhan Hansdah Nuhamalia, Mayurbhanj,
Kakharusole, Odisha, 757014

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SALKHAN HANSDA
KAKHARUSOLE
Nuhamalia
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