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Declaration

1) The document is a self-declaration form for an individual to request the issuance of residence, caste, income, OBC, or SEBC certificates. 2) It includes information about the applicant such as name, age, father/grandfather's name, village, and caste. 3) The applicant declares that the information provided is true and acknowledges they could face legal action if any information is found to be false.

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Kedar Pradhan
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4K views1 page

Declaration

1) The document is a self-declaration form for an individual to request the issuance of residence, caste, income, OBC, or SEBC certificates. 2) It includes information about the applicant such as name, age, father/grandfather's name, village, and caste. 3) The applicant declares that the information provided is true and acknowledges they could face legal action if any information is found to be false.

Uploaded by

Kedar Pradhan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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SELF DECLARATION FOR ISSUE OF RESIDENCE /CASTE/INCOME/OBC/SEBC CERTIFICATE

[ As per letter No RDM GOEB MISC 0043-2014 2878 date. 27-09-14 of Additional Chief
Secretary, Govt of Odisha ]

I ……… …………………………aged about……… …….Years,


.
S/o, D/o, W/o: …… …………of village: …… ……..
P.S.:…Talsara……Dist -Sundargarh, State Odisha do here by declare and state
as follows.

1) That, My father/Grandfather……………… …………..


S/o ………… ………………….is/was RT ICO RT of
Village……… … ………………under Khata no….

Wherein our caste is recorded as ……… ………but


Subsequently our fore father change their title from ……… …..to
……… ……….. Although we use the same caste.
2) That, our caste is………………… …………………, and family surname is
........ Which comes under Schedule … ….as per
ODISHA CASTE CERTIFICATE RULE, 1980(1) .

3) That, my …………………………………………………………name has been

mentioned in
RoR/Voter ID Card as……………………………………………..instead
Of……………………………………………………..and both are one and
same person i. e. ………………
4) That our family annual income from all sources is
Rs…………………………………./-
i.e. from agriculture is Rs ………………………………….../and from
... Daily Wages ......a source is Rs …………………………
6)5)That, I here
That with
ourfurnish
caste ismyself declaration in support ofsurname
…………………………..but my claim for issue of Residence/
is ………………..Which
Caste/OBC/SEBC
comes OBC/SEBC certificate
VideinSl.
favour of……..
No …………………..of ….……...
central /state list.

For the purpose of……………….

“I do hereby declare that the information given by me in this application form and its self attested enclosures is true to the
best of my knowledge and that the information furnished is exhaustive and I have not suppressed any fact That. I am solely
responsible for the accuracy of the declaration and information furnished and liable for action under section199 & 200 of
the Indian Penal code in case of wrong declaration & information. Also I am well aware of the fact that the certificate shall
be withdrawn in case of wrong declaration & information.” it is detected later on that any of the facts stated is wrong or
'that I have suppressed some material fact I shall be liable for prosecution under relevant law.

Date / 2022 L.T.I./Signature of the Applicant

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