SELF DECLARATION FOR ISSUE OF RESIDENCE /CASTE/INCOME/OBC/SEBC CERTIFICATE
[ As per letter No RDM GOEB MISC 0043-2014 2878 date. 27-09-14 of Additional Chief
Secretary, Govt of Odisha ]
I ……… …………………………aged about……… …….Years,
.
S/o, D/o, W/o: …… …………of village: …… ……..
P.S.:…Talsara……Dist -Sundargarh, State Odisha do here by declare and state
as follows.
1) That, My father/Grandfather……………… …………..
S/o ………… ………………….is/was RT ICO RT of
Village……… … ………………under Khata no….
Wherein our caste is recorded as ……… ………but
Subsequently our fore father change their title from ……… …..to
……… ……….. Although we use the same caste.
2) That, our caste is………………… …………………, and family surname is
........ Which comes under Schedule … ….as per
ODISHA CASTE CERTIFICATE RULE, 1980(1) .
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
... Daily Wages ......a source is Rs …………………………
6)5)That, I here
That with
ourfurnish
caste ismyself declaration in support ofsurname
…………………………..but my claim for issue of Residence/
is ………………..Which
Caste/OBC/SEBC
comes OBC/SEBC certificate
VideinSl.
favour of……..
No …………………..of ….……...
central /state list.
For the purpose of……………….
“I do hereby declare that the 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 section199 & 200 of
the Indian Penal code in case of wrong declaration & information. Also I am well aware of the fact that the certificate shall
be withdrawn in case of wrong declaration & information.” it is detected later on that any of the facts stated is wrong or
'that I have suppressed some material fact I shall be liable for prosecution under relevant law.
Date / 2022 L.T.I./Signature of the Applicant
