FORM-16

[ rule 14 ]
FOR STUDENTS

EDUCATION

*050520130101002236*

Application Form for verification of Scheduled Caste / Scheduled Caste convert to Buddhism/De-Notified Tribe (Vimukta Jati)/ Nomadic Tribe/Other Backward Class/Special Backward Category Certificate to be submitted to Divisional Caste Certificate Scrutiny Committee. To, Member Secretary and Research Officer, Divisional Caste Certificate Scrutiny Committee, Nagpur Division Committee No.3, Nagpur, A-Wing, Third Floor, New Administrative Building No 2,, Opposite to ZP, Civil Lines, Nagpur, Taluka : Nagpur Urban, District : Nagpur, State : Maharashtra, Pin Code : 440001

Affix Passport size Colour Photo

Sub :-

Verification of Scheduled Caste Caste Certificate.

Sir, I, the undersigned ABHISHEK RAJESH RAMTEKE hereby request to verify my Caste Certificate of Scheduled Caste Category. Following information and documents are submitted herewith in support of my caste claim :1. (a) Full name of the Applicant (as mentioned in Caste Certificate) ABHISHEK RAJESH RAMTEKE Present Address 9, PRABHAT COLONY NARI ROAD NAGPUR, NAGPUR, Taluka : Nagpur Urban, District : Nagpur, State : Maharashtra, Pin Code : 440026 (b) Mobile No. (c) E-Mail 9890212232 anandatra@yahoo.co.in

(d) Institute/College Sindhu Mahavidyalaya Name : Course Name : 12th Science Applicant's Institute/College Division : B Applicant's Institute/College Roll Number : 200 2. Caste/Sub Caste claimed by applicant Caste :Mahar (37), Sub Caste : NA 3. (a) Applicant's Birth date : 02/04/1997 (b) Applicant's Birth place : NAGPUR 4. Full Name of Applicant's Father RAJESH RAMTEKE (a) Fathers Date of Birth : 31/12/1966

NAGPUR (b) Fathers Birth Place : Permanent Address (If father is not alive please mention full address of his last residence.) 9, PRABHAT COLONY NARI ROAD NAGPUR, NAGPUR, Taluka : Nagpur Urban, District : Nagpur, State : Maharashtra, Pin Code : 440026

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5.

Full Name of applicant's Grand Father (Father's Father) PRABHAKAR RAMTEKE (a) Grand Father's Date of Birth : 01/05/1935 (b) Grand Father's Birth Place : NAGPUR Service

6.

Present occupation/service of applicant's Father Address with telephone number STATE BANK OF INDIA Address :RAMDASPETH, NAGPUR Telephone No : (Office)712-2441137 : B COM

7. 8. 9.

Father's Education

Inherited Profession of Family : (a) Applicant's Mother Tongue (b) Applicant's Regional Dialect (c) Applicant's God/Goddess : MARATHI : MARATHI : BUDDHA

(d) Five Surnames of applicant's Relative/persons from caste : MESHRAM, SHENDE, CHAHANDE, TABHANE, GAJBHIYE 10. Applicant's (a) Native Place (Address) : 9 PRABHAT COLONY NARI ROAD NAGPUR, NAGPUR, Taluka : Nagpur Urban, District : Nagpur, State : Maharashtra, Pin Code : 440026 (b) If applicant has left Native place Please specify when and who left the place and reason for leaving : Year of leaving:N.A Reason : N.A (c) Since when applicant is residing at present address. (d) At present who is residing at native place. Please give address and Telephone No. Person Name : Address : (e) Whether applicant is holding house/land at native place? 11. Yes Name of the competent authority from whom caste certificate is obtained and Certificate No. and Date. Competent Authority : DY COLLECTOR Certificate No:MRC-81/83400/2011-12 Issue Date:12/01/2012 (a) Name of district where certificate is issued : 12. Nagpur Telephone No : Person who left the native place:N.A

Name of the document on which basis caste certificate is obtained from competent authority. AFFIDAVIT, GUARDIAN CERTIFICATE, LEAVING CERTIFICATE, RESIDENT PROOF OF NAGAR SEVAK, PROOF OF CASTE BEFORE 1950 FOR SC RATION CARD, ELECTRIC BILL

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13.

Details of institution where applicant studied/studying Stage of Education Name of Educational Institute Educational Institute Address Duration of Education (Year) From To 2006 MAHAR 2012 MAHAR 2014 MAHAR 2002 2006 2012 Caste mentioned in educational institute's record

Primary Secondary College

MAHATMA GANDHI SCHOOL SRI GURU HARKRISHAN PUBLIC SCHOOL SINDHU MAHAVIDYALAY

JARIPATKA BEZON BAGH PANCHPAOLI

If applicant's father is literate, following information to be furnished 14. Stage of Name of Educational Educational Duration of Caste mentioned in Education Institute Institute Address Education (Year) educational institute's record From 1977 1978 1982 1987 To 1978 MAHAR 1982 MAHAR 1983 MAHAR 1988 MAHAR

Primary Secondary Secondary Primary 15.

MAHATMA GANDHI C.S E. SCHOOL MAHATMA GANDHI C.S E. SCHOOL, MODEL SCHOOL P W S COLLEGE

JARIPATKA,NAGPU R JARIPATKA, NAGPUR TEKA NAGPUR TEKA NAKA, NAGPUR

If applicant/applicant's family has migrated to Maharashtra state from other State, following information is to be furnished:Is applicant's family migrated to Maharashtra State ? If yes, from which State and when (Year)? No State :N.A Year :N.A No N.A.

16.

(a) Whether scrutiny of the caste certificate of any member of the family has been done earlier? (b) If Validity Certificate is received (enclose attested copy) Furnish Following Details (c) If Validity Certificate is rejected give its details below N.A

17.

(a) If applicant has applied for Caste Certificate No before any committee in the state. (b) If yes,which committee (c) For which Caste i ii Caste Category Sub Caste N.A N.A N.A N.A

(d) Date of application (e) Committee's decision 18. (a) Purpose of scrutiny

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Documents to be attached with application 19. (A) Following documents are attached only as per the sequence. Important Primary Documentary Evidence Original Caste Certificate of the Applicant Certified Copy of Caste Certificate of the Applicant Original Affidavit (In Specimen Form 3 Rule - 4(1)) Original Affidavit (In Specimen Form 17 Rule - 14) (Strike out whichever is not applicable) Attached Attached Attached Attached

Certificate by the Principal of College (As per the last para of FORM- Attached 16, Rule14) Attested Xerox copy of identity card issued by the college Attached (b-2) Any other documents supporting caste claim attached Yes

If any of the above documents are not available, then attach other relevent documents.(mention) CASTE CERTIFICATE OF APPLICANT, BIRTH CERTIFICATE OF APPLICANT, LEAVING CERTIFICATE OF 4TH CLASS, LEAVING CERTIFICATE OF FATHER OF 4TH CLASS, LEAVING CERTIFICATE OF UNCLE 4TH CLASS, AFFIDIVAT, I am producing certified copy of above documents with my application. I declare on oath that the information furnished by me in this application is true and correct. I am aware that incomplete application will be rejected and responsibility of making fresh application will be of mine. Place: Date : Yours,

(Signature of the Applicant's Father/Guardian)

Applicant's signature.

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Document Details Document Name Relation Caste Year

I am producing certified copy of above documents with my application. I declare on oath that the information furnished by me in this application is true and correct. I am aware that incomplete application will be rejected and responsibility of making fresh application will be of mine. Place: Date : (Signature of the Applicant's Father/Guardian) Applicant's signature. Yours,

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Certificate to be given by Principal of the School/College

This is to Certify that ABHISHEK RAJESH RAMTEKE is a Student of this School/College in Year 2013-14 and he/she is studying in 12th Science . His /Her name and other information is as per mentioned at number 2960 in general register. And the Caste stated as per our general register is ........................................................................ . (strike out if not applicable)

Place :Date:-

............................................................. Seal and Signature of the Principal / Head Master

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FORM - 3
[rule 4 (1)] AFFIDAVIT OF CLAIMANT/ PARENT(S) (Rule 4, Order 18 of the Code of Civil Procedure, 1908) I, .................. son / daughter of Shri/Smt. .........................................................................................., aged ............years, occupation................................................., residing at ................ village/ Town , , Tahsil, District , State here by solemnly affirm as under:2. I hereby give the genealogy tree of my family and relatives, which is as under: -

3. Other relevant submissions to be made or any essential explanation to be made, in support of Caste /Tribe claim, including the sociological, anthropological and ethnological (anthropological moorings and ethnological kinship), genetical trailts, of the Caste/Tribes, if any;

To the best of my knowledge and belief the information given in the application FORM -1 and in this affidavit is based on facts and is correct. Place: Date: Signature:............................................. (Name of the applicant/claimant)

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FORM-17
[rule 14]

FOR STUDENTS

Affidavit to be produced along with Caste Scrutiny Application Form

I Shri/Smt.___________________________________________________________________________ age ______years, Occupation ______________________, residing at ____________________________________________________, hereby solemnly affirm today dated ____________ that Caste Certificate of my son/daughter Number _______________________ dated ______________ given by __________________________________________________________________________ District ___________________________________ 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 from my paternal side 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 to be 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 mentioned information is true and correct, hence this affidavit.

Place :Date :-------------------------------------Signature of the Declarant

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