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Self Declaration Editable

This document is a self-declaration form for the issuance of Resident, Caste, Income, OBC, or SEBC certificates in Odisha. It requires the applicant to provide personal details, family background, caste information, and income sources, affirming the accuracy of the information provided. The applicant acknowledges responsibility for the declaration and potential consequences for any inaccuracies.

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Pravash Chandra Sahu
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2 views2 pages

Self Declaration Editable

This document is a self-declaration form for the issuance of Resident, Caste, Income, OBC, or SEBC certificates in Odisha. It requires the applicant to provide personal details, family background, caste information, and income sources, affirming the accuracy of the information provided. The applicant acknowledges responsibility for the declaration and potential consequences for any inaccuracies.

Uploaded by

Pravash Chandra Sahu
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

SELF-DECLARATION FOR ISSUE OF RESIDENT/CASTE/INCOME/OBC/SEBC

CERTIFICATE
(As per letter No. RDM-GOEB-MISC-0003-2014-28781 dt. 27.09.14 of Additional Chief Secretary, Govt. of Odisha)

I ______________________________ aged about ______ years


S/O, D/O, W/O ______________________________ of Vill. ______________________________
P.S. ______________________________ Dist. __________________ State: Odisha do hereby declare and state as follows:-

1) That, My father/grandfather ______________________________ S/O ______________________________


is/was R.T/CO R.T of village: ______________________________ under khata no. ______________________________ wherein our
caste is recorded as ______________________________, But subsequently our forefather change their title
from ______________________________ to ______________________________, although we use the same caste.

2) That, our caste is ______________________________ and family surname is ______________________________ which comes under
Scheduled ______________________________ as per ORISSA CASTE CERTIFICATE RULE,1980, 8 (IV).

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 ______________________________ source is Rs. __________________ /-

5) That, our caste is ______________________________, but surname is ______________________________ Which comes OBC/SEBC
vide Sl. No. __________________ of Central/State list.

6) That, I here with furnish my self-declaration in support of my claim for issue of Resident/
Caste/Income/OBC/SEBC certificate in favour of ______________________________
For the purpose of ______________________________

I do hereby declare that the above 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 section 199 and 200 of the Indian
Penal Code in case of wrong declaration and Information. Also, I am well aware of the fact that the
certificate shall be summarily cancelled and all the benefits availed by me shall be summarily
withdrawn in case of wrong declaration and Information.

Date: ____________________ Signature of the Applicant


Place: ___________________

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