FORM – 3

AFFIDAVIT OF CLAIMANT/PARENT(S)

(Rule 4, Order 18 of the Code of Civil Procedure, 1908)

I, Bhaskar Bhimrao Pagare Son of Shri Bhimrao Nimbaji Pagare, aged 46

years, occupations service, residence at Panchasheel Chawl Comitte , Jai Bhim Nagar ,
General Arun Kumar Vaidya Marge , Santosh Nagar , Goregaon East Mumbai
400065 ,village/Town , Goregaon East,Tahsil,Borivali ,District Mumbai Suburban, State
hereby solemnly affirm as under :-

2. I hereby give the genealogy tree of my family and relatives, which is under:-

BHIMRAO N PAGARE

GAUTAM B PAGARE BHASKAR B PAGARE

ASHOK B PAGARE PRAVIN B PAGARE

JAYESH A ROHAN A VISHAKHA PRATHMSH NIKITA G VEDIKA G SHUBHAM B GAUTAMI

PAGARE PAGARE P PAGARE P PAGARE PAGARE PAGARE PAGARE B PAGARE

3. Other relevant submission to be made or any essential explanation to be

made, in support of cast/Tribe claim, including the sociological an ethnological
(anthropological moorings and ethnological kinship), genetical traits, of the
caste/Tribes, if any:

To the best of my Knowledge and belief, the information given in the application
FROM -1 and in this affidavit is based on facts and is correct.

Place:

Date:

Signature ……………..........

(Bhaskar B. Pagare)

(Name of the applicant / claimant)

 FORM-17

[rule 14]

Affidavit to be produced along with Caste Scrutiny application Form.

I, Shri Bhaskar Bhimrao Pagare aged 46 years, Occupation Service, residing at

Panch sheel Chawl, Jay bhim nagar, gen AKV Marg, Santosh Nagar, Near
Nalanda Buddha Vihar, Goregaon (E), Mumbai – 400065. Hereby solemnly
affirm today dated………………………. That the caste certificate of my son/ daughter
Number……………………………. Dated……………………………… given by Tahasildar and
Executive Magistrate / Deputy Collector / Sub Divisional Officer Nashik District is
submitted for the Scrutiny.

The documents and proofs attached with the application From are
obtained by me from Competent Authority. These documents are true and
correct and obtained by the following proper procedure. No alteration/
correction/ change are made in these documents. I affirm hereby that these
documents are not duplicate or bogus.

*Cast Certificate of any relative was not invalidate 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 from 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:

Date:

(*Delete which is not applicable)

…………………………………………………

Signature of the Declarant