Annexure-IX

FORMAT FOR SC/ ST CERTIFICATE

A candidate who claims to belong to one of the Scheduled Caste or the Scheduled Tribes
should submit in support of his/ her claim an attested/certified copy of a certificate in the form given
below, from the District Officer or the sub-Divisional Officer or any other officer as indicated below
of the District in which his parents (or surviving parent) ordinarily reside who has been designated by
the State Government concerned as competent to issue such a certificate. If both his parents are dead,
the officer signing the certificate should be of the district in which the candidate himself ordinarily
resides otherwise than for the purpose of his own education. Wherever photograph is an integral part
of the certificate, the Commission would accept only attested photocopies of such certificates and not
any other attested or true copy.

(The format of the certificate to be produced by Scheduled Castes and Scheduled Tribes
candidates applying for appointment to posts under Government of India)

This is to certify that Shri/Shrimati/Kumari* __________________________ son/daughter of

___________________________________ of village/town*__________________ in
District/Division *_______________________ of the State/Union Territory* ________

belongs to the Caste/Tribes_______________ which is recognized as a Scheduled Castes/Scheduled

Tribes* under:-

The Constitution (Scheduled Castes) order, 1950 ___________________

The Constitution (Scheduled Tribes) order, 1950 ________________
The Constitution (Scheduled Castes) Union Territories order, 1951 * _______________
The Constitution (Scheduled Tribes) Union Territories Order, 1951*______________

As amended by the Scheduled Castes and Scheduled Tribes Lists(Modification) order, 1956,
the Bombay Reorganization Act, 1960 & the Punjab Reorganization Act, 1966, the State of Himachal
Pradesh Act 1970, the North-Eastern Area(Reorganization) Act, 1971 and the Scheduled Castes and
Scheduled Tribes Order(Amendment) Act, 1976.

The Constitution (Jammu & Kashmir) Scheduled Castes Order, 1956___________

The Constitution (Andaman and Nicobar Islands) Scheduled Tribes Order, 1959 as amended by the
Scheduled Castes and Scheduled Tribes order (Amendment Act), 1976*.
The Constitution (Dadra and Nagar Haveli) Scheduled Castes order 1962.
The Constitution (Dadra and Nagar Haveli) Scheduled Tribes Order 1962@.
The Constitution (Pondicherry) Scheduled Castes Order 1964@
The Constitution (Scheduled Tribes) (Uttar Pradesh) Order, 1967 @
The Constitution (Goa, Daman & Diu) Scheduled Castes Order, 1968@
The Constitution (Goa, Daman & Diu) Scheduled Tribes Order 1968 @
The Constitution (Nagaland) Scheduled Tribes Order, 1970 @
The Constitution (Sikkim) Scheduled Castes Order 1978@
The Constitution (Sikkim) Scheduled Tribes Order 1978@
The Constitution (Jammu & Kashmir) Scheduled Tribes Order 1989@
The Constitution (SC) orders (Amendment) Act, 1990@
The Constitution (ST) orders (Amendment) Ordinance 1991@
Page 85 of 113
The Constitution (ST) orders (Second Amendment) Act, 1991@
The Constitution (ST) orders (Amendment) Ordinance 1996@
The Scheduled Caste and Scheduled Tribe Orders (Amendment ) Act 2002@
The Constitution (Scheduled Caste) Orders(Amendment) Act 2002@
The Constitution(Scheduled Caste and Scheduled Tribe) Orders (Amendment) Act 2002@
The Constitution (Scheduled Caste) Order (Amendment) Act 2007@
%2. Applicable in the case of Scheduled Castes, Scheduled Tribes persons who have migrated from
one State/Union Territory Administration.

This certificate is issued on the basis of the Scheduled Castes/ Scheduled Tribes certificate
issued to Shri/Shrimati __________________________Father/mother of
Shri/Shrimati/Kumari*___________________________of village/town*______________________
in District/Division* ______________________of the State/Union
Territory*______________________________ who belong to the
_________________________________ Caste/Tribe which is recognized as a Scheduled
Caste/Scheduled Tribe in the State/Union Territory* issued by
the___________________________________dated____________________________.

%3. Shri/Shrimati/Kumari and /or * his/her family ordinarily reside(s) in

village/town*________________________________________ of ________________
District/Division* _________________of the State/Union Territory of
____________________________

Signature__________________________

** Designation________________________

(with seal of office)

Place______________

Date_______________

* Please delete the words which are not applicable

@ Please quote specific presidential order

% Delete the paragraph which is not applicable.

NOTE: The term ordinarily reside(s) used here will have the same meaning as in section 20 of the
Representation of the People Act, 1950.

** List of authorities empowered to issue Caste/Tribe Certificates:

Page 86 of 113
(i) District Magistrate/Additional District Magistrate/Collector/Deputy Commissioner/Additional
Deputy Commissioner/[Link]/Ist Class Stipendiary Magistrate/Sub-Divisional
Magistrate/Extra-Assistant Commissioner/Taluka Magistrate/Executive Magistrate.

(ii) Chief Presidency Magistrate/Additional Chief Presidency Magistrate/Presidency Magistrate.

(iii) Revenue Officers not below the rank of Tehsildar.

(iv) Sub-Divisional Officers of the area where the candidate and/or his family normally resides.

NOTE: ST candidates belonging to Tamil Nadu State should submit caste certificate ONLY FROM
THE REVENUE DIVISIONAL OFFICER.

Page 87 of 113
 Annexure-X

(FORM OF CERTIFICATE TO BE PRODUCED BY OTHER BACKWARD CLASSES

APPLYING FOR APPOINTMENT TO POSTS UNDER THE GOVERNMENT OF INDIA)

This is to certify that Shri/Smt./Kumari _________________________son/daughter of

_______________________________ of village/town _________________________

in District/Division ________________________________ in the State/Union

Territory ____________________________ belongs to the __________________ Community
which is recognized as a backward class under the Government of India, Ministry of Social Justice
and Empowerment‟s Resolution No. _________________________ dated _________________*.
Shri/Smt./Kumari __________________________ and/or his/her family ordinarily reside(s) in the
______________________ District/Division of the ____________________________ State/Union
Territory. This is also to certify that he/she does not belong to the persons/sections (Creamy Layer)
mentioned in Column 3 of the Schedule to the Government of India, Department of Personnel &
Training O.M. No. 36012/22/93-Estt (SCT) dated 8.9.1993**.

District Magistrate: ________________________________________

Deputy Commissioner etc.: __________________________________

Dated:

Seal:

* The authority issuing the certificate may have to mention the details of Resolution of Government
of India, in which the caste of the candidate is mentioned as OBC.

** As amended from time to time.

Note: The term ”Ordinarily” used here will have the same meaning as in Section 20 of the
Representation of the People Act,1950.

Page 88 of 113
 Annexure-XI

Government of ...............

(Name & Address of the authority issuing the certificate)

INCOME & ASSEST CERTIFICATE TO BE PRODUCED BY ECONOMICALLY WEAKER

SECTIONS

Certificate No. ____________ Date _________________

VALID FOR THE YEAR__________

This is to certify that Shri/Smt./Kumari _________________________son/daughter/wife of

______________permanent resident of ___________________,
Village/Street_____________PostOffice___________________District___________________in the
State/ Union Territory___________________PinCode__________whose photograph is attested
below belongs to Economically Weaker Sections, since the gross annual income* of his/ her
„family‟** is below Rs. 8 Lakh (Rupees Eight Lakh only) for the financial year ________ His/ her
family does not own or possess any of the following assets *** :

I. 5 acres of agricultural land and above;

II. Residential flat of 1000 sq. ft. and above;

III Residential plot of 100 sq. yards and above in notified municipalities;

IV Residential plot of 200 sq. yards and above in areas other than the
notified municipalities.

2. Shri/Smt./Kumari________________________belongs to the ______________caste

which is not recognized as a Scheduled Caste, Scheduled Tribe and Other Backward Classes (Central
List).

Signature with seal of Office_____________________________

Name____________________________________

Designation_________________________

Page 89 of 113
Recent Passport size attested
photograph of the applicant

*Note 1: Income covered all sources i.e. salary, agriculture, business, profession etc.

** Note 2: The term „Family‟ for this purpose include the person, who seeks benefit of
reservation, his/ her parents and siblings below the age of 18 years as also his/her spouse and
children below the age of 18 years.

***Note 3: The property held by a “Family” in different locations or different places/cities

have been clubbed while applying the land or property holding test to determine EWS status.

Page 90 of 113
 Annexure-XII

Form-V
Certificate of Disability

(In cases of amputation or complete permanent paralysis of limbs or dwarfism and in case of
blindness)
[See rule 18(1)]
(Name and Address of the Medical Authority issuing the Certificate)

Recent passport size

attested photograph

(Showing face only) of

the person with disability.

Certificate No. Date:

This is to certify that I have carefully examined Shri/Smt./Kum.

____________________________son/wife/daughter of Shri __________________ Date of Birth
(DD/MM/YY) ____________ Age ______ years, male/female __________________ registration No.
______________permanent resident of House No. ___________ Ward/Village/Street
__________________ Post Office _______________ District __________ State ________________,
whose photograph is affixed above, and am satisfied that:

(A) he/she is a case of:

 locomotor disability
 dwarfism
 blindness

(Please tick as applicable)

(B) the diagnosis in his/her case is __________________

(C) he/she has ________ % (in figure) __________________ percent (in words) permanent
locomotor disability/dwarfism/blindness in relation to his/her ______ (part of body) as per guidelines
( ……………number and date of issue of the guidelines to be specified).

2. The applicant has submitted the following document as proof of residence:-

Nature of Document Date of Issue Details of authority issuing

certificate

(Signature and Seal of Authorised Signatory of

notified Medical Authority)
Signature/thumb impression of the person in whose favour certificate of disability is issued

Page 91 of 113
 Annexure-XIII

Form - VI
Certificate of Disability
(In cases of multiple disabilities)
[See rule 18(1)]
(Name and Address of the Medical Authority issuing the Certificate)

Recent passport size

attested photograph

(Showing face only) of

the person with disability.

Certificate No. Date:

This is to certify that we have carefully examined Shri/Smt./Kum.

_____________________________________son/wife/daughter of Shri
_____________________________________Date of Birth (DD/MM/YY) ____________ Age _____
years, male/female ______________.

Registration No. _______________ permanent resident of House No. ____________

Ward/Village/Street ____________ Post Office ____________ District ____________ State
____________, whose photograph is affixed above, and am satisfied that:

(A) he/she is a case of Multiple Disability. His/her extent of permanent physical impairment/disability
has been evaluated as per guidelines (……………number and date of issue of the guidelines to be
specified) for the disabilities ticked below, and is shown against the relevant disability in the table
below:

S. No Disability Affected part Diagnosis Permanent physical

of body impairment/mental
disability (in %)

1. Locomotor disability @

2. Muscular Dystrophy

3. Leprosy cured

4. Dwarfism

5. Cerebral Palsy

6. Acid attack Victim

7. Low vision &

Page 92 of 113
 8. Blindness &

9. Deaf £

10. Hard of Hearing £

11. Speech and Language

disability

12. Intellectual Disability

13. Specific Learning

Disability

14. Autism Spectrum

Disorder

15. Mental illness

16. Chronic Neurological

Conditions

17. Multiple sclerosis

18. Parkinson‟s disease

19. Haemophilia

20. Thalassemia

21. Sickle Cell disease

(B) In the light of the above, his/her over all permanent physical impairment as per guidelines
(……….number and date of issue of the guidelines to be specified), is as follows:

In figures: - ------------------ percent

In words:- --------------------------------------------------------------------------- percent

2. This condition is progressive/non-progressive/likely to improve/not likely to improve.

3. Reassessment of disability is :

i. not necessary,

or

ii. is recommended/after ............... years ................ months, and therefore this certificate shall
be valid till ----- ----- ------

(DD) (MM) (YY)

Page 93 of 113
 @ e.g. Left/right/both arms/legs
& e.g. Single eye
£ e.g. Left/Right/both ears
4. The applicant has submitted the following document as proof of residence:

Nature of document Date of issue Details of authority issuing

certificate

5. Signature and seal of the Medical Authority.

Name and Seal of Member Name and Seal of Member Name and Seal of the Chairperson

Signature/thumb impression of the person in

whose favour certificate of disability is issued.

Page 94 of 113
 Annexure-XIV

Form – VII
Certificate of Disability
(In cases other than those mentioned in Forms V and VI)
(Name and Address of the Medical Authority issuing the Certificate)
(See rule 18(1))

Recent passport size attested photograph (Showing face only) of the person with disability

Certificate No. Date:

This is to certify that I have carefully examined

Shri/Smt./Kum. __________________________________________ son/wife/daughter of Shri

__________________________________________ Date of Birth (DD/MM/YY)_____ _____ ____
Age _______ years, male/female _________ Registration No. __________________ permanent
resident of House No. ___________ Ward/Village/Street _____________________ Post Office
_________________ District ________________ State ____________________, whose photograph
is affixed above, and am satisfied that he/she is a case of ______________________________
disability. His/her extent of percentage physical impairment/disability has been evaluated as per
guidelines (……..number and date of issue of the guidelines to be specified) and is shown against the
relevant disability in the table below:

S. No Disability Affected part Diagnosis Permanent physical

of body impairment/mental disability
(in %)

1. Locomotor disability @

2. Muscular Dystrophy

3. Leprosy cured

4. Cerebral Palsy

5. Acid attack Victim

6. Low vision &

7. Deaf €

8. Hard of Hearing €

9. Speech and Language

disability

10. Intellectual Disability

11. Specific Learning

Page 95 of 113
 Disability

12. Autism Spectrum

Disorder

13. Mental illness

14. Chronic Neurological

Conditions

15. Multiple sclerosis

16. Parkinson‟s disease

17. Haemophilia

18. Thalassemia

19. Sickle Cell disease

(Please strike out the disabilities which are not applicable)

2. The above condition is progressive/non-progressive/likely to improve/not likely to improve.

3. Reassessment of disability is:

(i) not necessary, or

(ii) is recommended/after _______ years ______________ months, and therefore this certificate shall
be valid till (DD/MM/YY) ____ ____ ____

@ - eg. Left/Right/both arms/legs

& - eg. Single eye/both eyes

€ - eg. Left/Right/both ears

4. The applicant has submitted the following document as proof of residence:

Nature of document Date of issue Details of authority issuing

certificate

(Authorized Signatory of notified Medical Authority)

(Name and Seal)

Page 96 of 113
 Countersigned
{Countersignature and seal of the
Chief Medical Officer/Medical Superintendent/
Head of Government Hospital, in case the
Certificate is issued by a medical authority who is
not a Government servant (with seal)}

Signature/thumb impression of the person in

whose favour certificate of disability is issued

Note: In case this certificate is issued by a medical authority who is not a Government servant, it shall
be valid only if countersigned by the Chief Medical Officer of the District

Page 97 of 113
 ANNEXURE - XV

FORM OF MEDICAL CERTIFICATE TO BE PRODUCED BY OH CANDIDATES WITH

BENCHMARK DISABILITY WHO SEEK EXEMPTION FROM APPEARING IN THE SKILL
TEST (DEST) FOR CGLE – .

This is to certify that Sh./Smt./Kum _____________son/daughter/wife of

Shri______________is suffering from ________________.

Clinical diagnosis as a result of which he/ she has the following disabilities. (Brief description of his/
her disabilities) -------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------

This is a permanent disability and the extent of his/ her disability works out to ____% of disability.

This disability is likely to interfere with Typewriting (specify)

---------------------------------------------------------------------------------------------------------

Signature of Civil Surgeon:

Name:

(Official Stamp)

Place:

Photograph of candidate clearly showing face with affected portion of the body

Date:

Signature of candidate:

Name:

Page 98 of 113