ANNEXURE-A

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 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 Corporation would accept only attested photocopies of such certificates and
not any other attested or truecopy.
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)ScheduledCastes 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 Order1978@ 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@ The Constitution (ST) orders (Second
Amendment) Act, 1991 @ The Constitution (ST) orders (Amendment) Ordinance 1996
The Scheduled Caste and Scheduled Tribes Orders (Amendment) Act,2002 The Constitution(Scheduled Caste)
Orders (Amendment) Act, 2002
The Constitution (Scheduled Caste and Scheduled Tribes) Orders (Amendment) Act,2002
% 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/UnionTerritory* issued by the __________________________________ dated__________________.

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

village/town*______________________________________of __________________________ District/Division*

23
____________________________ 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-I : 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:
[Link] Magistrate/ Additional District Magistrate/ Collector/ Deputy Commissioner/ Additional Deputy
Commissioner/ Dy. Collector/ Ist Class Stipendiary Magistrate/ Sub-Divisional Magistrate/ Extra-Assistant
Commissioner/ Taluka Magistrate/ Executive Magistrate.
[Link] 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-II: ST candidates belonging to Tamil Nadu state should submit caste certificate ONLY FROM THE
REVENUE DIVISIONAL OFFICER.

24
 ANNEXURE-B

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
recognised 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.
**- Or further modified vide O.M. No. 36033/2013-Estt (Res.) dated 27.05.2013 or further modified vide O.M. No.
36033/1/2013-Estt (Res.) dated 13.09.2017 or latest notification of the Government of India.

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

25
 ANNEXURE-C

Government of……………..
(Name & Address of the authority issuing the certificate)

INCOME & ASSET 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………………………Post Office……………………
District…………………..in the State/Union Territory…………………………..Pin Code…………………. 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;
Ill. 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……………………………….

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.

NOTE-1 :-

The Income and Asset Certificate issued 'by any one of the following authorities in the prescribed format as
given above shall only be accepted as proof of candidate's claim as 'belonging to EWS: -

(i) District Magistrate/Additional District Magistrate/ Collector/ Deputy Commissioner/Additional Deputy

Commissioner/ 1st Class Stipendiary Magistrate/ Sub-Divisional Magistrate/ Taluka Magistrate/
Executive Magistrate/ Extra Assistant Commissioner,
(ii) Chief Presidency Magistrate/Additional Chief Presidency Magistrate/ Presidency Magistrate,
(iii) Revenue Officer not below the rank of Tehsildar and
(iv) Sub-Divisional Officer or the area where the candidate and/or his family normally resides.

26
 ANNEXURE-D1
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 __________________

1. 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

27
 ANNEXURE-D2
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 Diagnosis Permanent physical impairment/mental
part of disability (in %)
body

1. Locomotor disability @
2. Muscular Dystrophy
3. Leprosy cured
4. Dwarfism
5. Cerebral Palsy
6. Acid attack Victim
7. Low vision #
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

28
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)

@ e.g. Left/right/both arms/legs
# e.g. Single eye
£ e.g. Left/Right/both ears
[Link] 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.

29
 ANNEXURE-D3

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 Diagnosis Permanent physical impairment/mental
part of disability (in %)
body
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
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

30
(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

(Authorised Signatory of notified Medical Authority)

(Name and Seal)

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

31
 ANNEXURE-E

Certificate regarding physical limitation of an examinee to write

This is to certify that, I have examined Mr/Ms/Mrs _____________________________________ (name of the

candidate with disability), a person with _______________________________________ (nature and percentage
of disability as with mentioned in the certificate of disability), S/o/D/o ______________________________, a
resident of _______________________ (Village/ District/State) and to state that he/she has physical limitation
which hampers his/her writing capabilities owing to his/her disability.

Signature
Chief Medical Officer/ Civil Surgeon/ Medical Superintendent of a
Government health care institution
Name & Designation.
Name of Government Hospital/ Health Care Centre with Seal

Place:
Date:

Note:
Certificate should be given by a specialist of the relevant stream/ disability (eg. Visual impairment -
Ophthalmologist, Locomotor disability - Orthopaedic specialist/PMR).

32
 ANNEXURE-F

DECLARATION

We, the undersigned, Shri/Smt/Kum. ________________________________________________ eligible

candidate having qualification _______________________________ and Shri/Smt./Kum.
________________________________________________eligible writer (Scribe) having qualification
_______________________________ for the eligible candidate, do hereby declare that:
1. The scribe is identified by the candidate at his/her own cost and as per own choice.
2. In case it is found that the qualification of the Scribe is not as declared by the candidate and the qualification of
the Scribe is not one step below the qualification of the candidate taking examination, his/her candidature shall
liable to be summarily rejected. In such case the candidate shall forfeit his/her right to the post and claims relating
thereto.
3. The candidate is a person with benchmark disabilities in the category of blindness, loco-motor disability (both
arms affected-BA) and cerebral palsy.
4. In case of other category of persons with benchmark disabilities, the candidate can be allowed the provisions of
the scribe provided that at the time of document verification, he/she has to produce the requisite certificate issued
by Chief Medical Officer/Civil Surgeon/Medical Superintendent of a Government health care institution in the
prescribed proforma(Annexure-E) to the effect that I have physical limitation to write, and scribe is essential to
write examination on my behalf, as per the provisions of Ministry of Social Justice & Empowerment O.M. No. 34-
02/2015-DD-III dated 29th August, 2018.
5. As per the rules, the candidate availing services of a scribe is eligible for compensatory time of 20 minutes for
every hour of the examination.
6. In view of the importance of the time element and the examination being of a competitive nature, the candidate
undertakes to fully satisfy the Medical Officer of the Organization that there was necessity for use of a scribe as
his/her writing speed is affected by the disabilities mentioned in Point 3 above.
7. The candidate has ensured that the scribe is not a candidate for the same recruitment exercise.
8. The scribe has ensured that he/she is not appearing in the same recruitment exercise.
9. All the above statements made by us are true and correct to the best of our knowledge and belief. We also
understand that in case it is detected at any stage of recruitment that we do not fulfill the eligibility norms and/or
that the information furnished by us is incorrect/false or that we have suppressed any material fact(s), the
candidature of the applicant (both the candidate as well as scribe in case he/she has appeared in the same
examination) will stand cancelled, irrespective of the result of the examination. If any of these shortcoming(s)
is/are detected even after the candidate's appointment, his/her services are liable to be terminated. In such
circumstances, both signatories will be liable to criminal prosecution.

I, ____________________________________ (Name of Scribe) certify that I am not a candidate for this

recruitment.
I, ____________________________________ (Name of candidate) the candidate for this recruitment certify that
I have ensured that the above scribe is not appearing for this recruitment.

Given under are our signature and contact details: -

SCRIBE CANDIDATE
Signature: Signature:
Name: Name:
Address:
Photo of the Scribe Contact No.: Contact No.:

____________________
Signature of Invigilator

33