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Suhas Self Declaration

This document is a self-declaration certificate for the issuance of Resident/Caste/Income/OBC/SEBC certificates in Odisha. It includes personal details, caste information, family income, and a declaration of the truthfulness of the provided information. The applicant acknowledges responsibility for the accuracy of the information and the consequences of any false declarations.

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santanpattayat111
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604 views1 page

Suhas Self Declaration

This document is a self-declaration certificate for the issuance of Resident/Caste/Income/OBC/SEBC certificates in Odisha. It includes personal details, caste information, family income, and a declaration of the truthfulness of the provided information. The applicant acknowledges responsibility for the accuracy of the information and the consequences of any false declarations.

Uploaded by

santanpattayat111
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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CERTIFICATE

RESIDENT/CASTE/INCOME/OBC/SE BC tarv
Addition Chief Secre
OF of
FORISSUE
dt.27.09.14
SELF-DECLARATION
RDM-GOEB-MISC-0043-2014-28781

No. aged about 5 years,


(As Derletter
Srehas kumer of Vill
ceh al?
Jdenaallk hereby declare and state as
s/0,D/0,W/o State: Odisha do
Dist
P5.
follows -
father/grandfather where in our
1 That, My under khata no
village change their title
Is/was R.T/CO R.T of forefather
recorded as ,But subsequently our
caste is
MalLKalthough we use the same caste.
to
fram which comes
and family surname is
2. That, our caste is RULE, 1980,8(1).
under scheduled as perORISSA CASTECERTIFICATE
ROR/Voter ID card
name has been mentioned in
3. That, my and
Gaerl Naik nstesd of
both are one- and same person i.e Gauti
is Rs
Malbk
i.e. from agriculture is
4. That, our family annual income from all sourbes
Rs. and from sOurce is Rs.

5. That, our caste Is but surname is which comes


OBC/SEBC vide sl.no. of Central/State list.
6. That, 1here with finish my self-declaration insupport of my claim for issue of Resident
/Caste/Income/0BC/SÉBC certificate in favour of
For the purpose of
1do hereby declare that the above Information
given by me in this application form and
itself-attested enclosures ls true to the best of my knowledge and that the information finishied
is exhaustive and I have not suppressed any
of the decaration and information fact. That, tam solely respanslble for the accuracy
the indian PenalCode in case of wrong
furnished and liable for action under section 199 and
fact that the certificate shall be declaration and information. Also,lan well aware 200of
summarily withdrawn in case ofsummarily cancelled and all the benefits availed by me of the
wrong declaration and shall be
information.
Date: 05 0S 2035
Place:
K SuheS
Signature of theKemTL
Applicant Mallik

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