APPLICATION FORM FOR SCHEDULED CASTE CERTIFICATE

Warning: It is an offence to give false information in this form.

To,

Deputy Commissioner.........................................
Delhi

1. Name (in BLOCK letters) :

2. Father’s/Husband’s Name :

3. Permanent Address :

4. Complete present address with name of Police Station :

5. Ration Card Number :

6. Date and place of birth :

7. Is he/she scheduled caste since birth or by adoption :

8. Nationality :

9. Caste :

10. Religion :

11. Duration of stay in Delhi (with date) Date Month Year

12. Complete address of father before migration to Delhi :

13. If migrated after or before 20-9-1951 in Delhi, give Date Month Year
date of migration

14. The state to which ancestors belong to :

15. Educational Qualification :

16. Name of School / College last attended

(attach an attested copy of the Education Certificate) :

17. Purpose for which the certificate is required :

18. Have your parents/or any of your family member
been is issued Scheduled Cast Certificate from
Delhi. If so, attach an attested copy of that
S.C. Certificate :

19. Have you obtained scheduled caste certificate from

Delhi or any other State? Give the answer in Yes or No :
If Yes please give full detail

20. (1) Full Name (in BLOCK letters)

Full address (House No., Street, Locality)

(2) Full Name (in BLOCK letters)

Full address House No., Street, Locality)

Signature of the applicant

Name (in BLOCK letters)… … … … … … … … … … … … … … .

Full Address… … … … … … … … … … … … … … … … … … … ..

… … … … … … … … … … … … … … … … … … … … … … … … ..

Declaration :
(To be signed by applicant if he/she attained the age of 18 years. In case he/she is minor it will be
signed by father/guardian of the applicant)

I, … … … … … … … … … … … … … … … … … … … … … … … … , son of/daughter of/ wife of

… … … … … … … … … … … … … … … … … … … … … … … … … … do hereby declare that the
facts given in the application are correct and nothing has been concealed therefrom.

Signature of the applicant

Name (in BLOCK letters)… … … … … … … … … … … … … … .

Caution: It is an important document and should be attested on the basis of personal

knowledge. If the scheduled caste certificate is issued on the basis of wrong
attestation then the action can be taken against the attestator under Indian Penal
Code.
 ATTESTION

I certify that Shri/Km./Smt. … … … … … … … … … … … … … … … … … … … … . son

of/daughter of/wife of … … … … … … … … … … … … … … … … … … … … . is known to me for
the last … … … … … … … … years and he/she belongs to … … … … … … … … … … caste and
he/she was born at … … … … … … … … … … … … (place of birth). I also certify personally
that the facts given in this form are correct.

Signature of the applicant

Name (in BLOCK letters)… … … … … … … … … … … … … … .

Full Address of the office ..… … … … … … … … … … … … … ..

… … … … … … … … … … … … … … … … … … … … … … … … ..

Telephone No. … … … … … … … … … … … .

Full Residential Address ..… … … … … … … … … … … … … ..

… … … … … … … … … … … … … … … … … … … … … … … … ..

Telephone No. … … … … … … … … … … … .

The above attestation can be done by any of the following officers:-

1. Member of Parliament/Member of Metropolitan Council/Member of Harijan Welfare
Board, Delhi and Member of Corporation, Delhi.
2. Gazetted Officer of Delhi Administration/Central Government.
3. Police Officer not below the rank of D.S.P.