Rs.

10/
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Reference No.
344RTT
TYeT RaT 3ATd Application Date ApplantsPhoto
No. 104735
Applicabion for Caste Certficate Scheduled Caste/ Scheduled Caste Vonvets to Buddhism / De Noffled
Tribed (Vimukt Jat) Nomadic Tribes/ Other Backward Classes/Special Backward Category/ Maratha (SEBC)

¥TRreT TYyitT / Appllcant Detalls

3TTT 4ts/ Aadhaar Number

H aFull Name
Female(( )
/Female T/Other (
fT/Gender T /Male
r t E / Date of Birth
eRr ET/Occupaton ofApplant
ATEIT THT/Residence Address
(Please Provide the following detalls)

B./ House/ Flat No.

HTTA E./3/Buiding No./ Name
FT / Society Complex
/Villag U/Taluka
TRT 7/Road Name
Ter T/ Name of Post Office /District 77S/Pin Code
1444 dT/Pemanent Addresss

(Fill in different from above)

T/ F . /House/ Flat No.

HTT 5./ HiT/ Bulding No. / Name

AT HFT/ Soclety Complex
i/VIllage Tg/Taluka
TRTNT/ Road Name
TR Name of Post Office
fTDistrict fts/Pin Code
y4Eai 5. / Mobille No.

- E-mail

aaHrT/Occupation

T i t / Caste Details
kauea frare a/Aplican's Father's Detals

p ia Full Name

Caste Certiflcate 1-4

Address(If not allve, address of his last)
FHAI . / House/ Flat No.
4TT . / TG/Bullding No./ Name
reT IT/ SOciety /Complex
AT TI Road Name t/Village ITT/Taluka
teT 1/ Name of Post Office fr7s/Pin Code
fTDistrict
4 Occupation oft Applicant

Certificate applied for Scheduled De-notlfed Nomadic Other Speclal

Caste Tribes Tribes Backward Backward (SCBC) Maratha
(Vimukt Jatl) Classes Category Cast

Sub Caste

FTTe THÍPT Bepeflclary Detalls

T a Fll Name
TTTrtE/ Date of Birh MiM YYYY

Application Relation to Beneficiary

7 foam/ Place of Birth

Sub Ordinary place of Residence

(if Different from above) Vlage. g/Taluka
TDistrict frs/Pin Code
HriTT a$/Place of Birth
FITTT KT Reason of Migration
aTHTAT tafora aufTFT/ Educatlon Detalls of Beneflclary

Board/University Name&Address of Institute Start Year End Year

Qualification

Whether Applicant's 7Yes 1 TEV No

relative
been issued a caste
certficate of Detalls of benefits
availed Govt. benefits avalled
of the basis
of caste/ tribe claimm

Caste Certiflicate 1-2

 /Yes TbNo[

(TETE) IfYes, detalls of application

Have you Applied before / Yes1 TE/ No[ ,I
Was Certficate given ?
for Caste Certficate
(Including other states) Place of application
Dateof Applicaton
DD MM YYYY
|( T I ATECt 3ffATd Flled marked with "are mandatory)

UEUIR

foaT

eyywss ssss

List of documents to be attached (marklin case rnecessary aniesuré are attached alse mark [X]

3HTOR5 EA/ Mantatory DocumentsS

3HTeTR IS (TIATÍ a HiCrT) ATaRY7

Caste Certificate 1-3

 ) HTTat fcaII 37Haa aTet/ aTat (ST/SC)

) f a Tt, HeT TAIr (VINT)

) T r it, KeT 3HTG (VINT) ait3/t/ 4aTa Rata

SBC ) is. srer

)R HTOTHqutT a tay HTOTHYIakT (OBC
13
0BC

sirR
HIMITHaoiy a TarT HTUTT YCUIoRT (OBC / SBC )Rois. 13
1E6

SEBC )HTOI YeOTnkaT (SEBC) ia. 13 sHFTT PREb yait ArETrtr 5o IT

Caste Certiflcate 4-4