FORM-17 [rule 14]

Affidavit to be produced along with Caste Scrutiny application Form

I,Shri JITENDRA SHALIGRAM UDAWANT age 39 years, Occupation Self Employed residing at
Shrikrushna Nagar, Bhairavnath Hos. Soc, Maparwadi Road, Sinnar Dist, Nashik 422103. hereby
solemnly affirm today dated / / that my caste certificate
Number .................................................. dated .............................................. given by Tahasildar
and Executive Magistrate / Deputy Collector / Sub Divisional Officer Sinnar District Nashik is
submitted for the Scrutiny.
The documents and proofs attached with the application Form are obtained by me from
Competent Authority. These documents are true and correct and obtained by following proper
procedure. No alteration / correction / change are made in these documents. I affirm hereby that
these documents are not duplicate or bogus.

*Caste Certificate of any relative was not invalidated by the Scrutiny Committee.

*And it is not a case that I applied before any Caste Certificate Scrutiny Committee in
Maharashtra and my caste certificate is invalidated.

I will be responsible, If the documents and proofs attached with the application form are found
incorrect or bogus, and I am aware that I will be liable for punishment under provision of Indian
Penal Code.

I declare that the above mention information is true and correct, hence this affidavit.

Place: SINNAR Jitendra Shaligram Udawant

Date: Signature of the Declarant

Identified By:

Mr. Pavan Ashok Varma

Address: Wavi, Sinnar