FORMAT FOR SC/ ST CERTIFICATE
A candidate who claims to belong to one of the Scheduled Caste or the Scheduled Tribes should submitinsupportofhis/herclaimanattested/certifiedcopyofacertificateintheformgivenbelow,fromthe DistrictOfficerorthesub-DivisionalOfficeroranyotherofficerasindicatedbelowoftheDistrictinwhichhis parents(orsurvivingparent)ordinarilyresidewhohasbeendesignatedbytheStateGovernmentconcerned ascompetenttoissuesuchacertificate.Ifbothhisparentsaredead,theofficersigningthecertificateshould beofthedistrictinwhichthecandidatehimselfordinarilyresidesotherwisethanforthepurposeofhisown education. Wherever photograph is an integral part of the certificate, the Commission would accept only attestedphotocopiesofsuchcertificatesandnotanyotherattestedortruecopy.
(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 ScheduledCastes/ScheduledTribes*under:-
TheConstitution(ScheduledCastes)Order,1950
TheConstitution(ScheduledTribes)Order,1950
TheConstitution(ScheduledCastes)UnionTerritoriesOrder,1951*
TheConstitution(ScheduledTribes)UnionTerritoriesOrder,1951*
As amended by the Scheduled Castes and Scheduled Tribes Lists (Modification) Order, 1956, the BombayReorganizationAct,1960&thePunjabReorganizationAct,1966,theStateofHimachalPradeshAct 1970,theNorth-EasternArea(Reorganization) Act,1971andtheScheduledCastes andScheduledTribes Order(Amendment)Act,1976.
TheConstitution(Jammu&Kashmir)ScheduledCastesOrder,1956
TheConstitution(AndamanandNicobarIslands)ScheduledTribesOrder,1959asamendedbythe ScheduledCastesandScheduledTribesOrder(AmendmentAct),1976*.
TheConstitution(DadraandNagarHaveli)ScheduledCastesOrder1962.
TheConstitution(DadraandNagarHaveli)ScheduledTribesOrder1962@.
TheConstitution(Pondicherry)ScheduledCastesOrder1964@
TheConstitution(ScheduledTribes)(UttarPradesh)Order,1967@
TheConstitution(Goa,Daman&Diu)ScheduledCastesOrder,1968@
TheConstitution(Goa,Daman&Diu)ScheduledTribesOrder1968@
TheConstitution(Nagaland)ScheduledTribesOrder,1970@
TheConstitution(Sikkim)ScheduledCastesOrder1978@
TheConstitution(Sikkim)ScheduledTribesOrder1978@
TheConstitution(Jammu&Kashmir)ScheduledTribesOrder1989@
TheConstitution(SC)Orders(Amendment)Act,1990@
TheConstitution(ST)Orders(Amendment)Ordinance1991@
TheConstitution(ST)Orders(SecondAmendment)Act,1991@
TheConstitution(ST)Orders(Amendment)Ordinance1996@
TheScheduledCasteandScheduledTribeOrders(Amendment)Act2002@ TheConstitution(ScheduledCaste)Orders(Amendment)Act2002@
TheConstitution(ScheduledCasteandScheduledTribe)Orders(Amendment)Act2002@ TheConstitution(ScheduledCaste)Order(Amendment)Act2007@
%2. ApplicableinthecaseofScheduledCastes,ScheduledTribespersonswhohavemigratedfromone State/UnionTerritoryAdministration.
ThiscertificateisissuedonthebasisoftheScheduledCastes/ScheduledTribescertificateissuedto Shri
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 Territoryof______________________
Place Date
*Pleasedeletethewordswhicharenotapplicable @Pleasequotespecificpresidentialorder %Deletetheparagraphwhichisnotapplicable.
NOTE:Theterm ordinarilyreside(s) usedherewillhavethesamemeaningas inSection20of the RepresentationofthePeopleAct,1950.
**ListofauthoritiesempoweredtoissueCaste/TribeCertificates:
(i) District Magistrate/Additional District Magistrate/Collector/Deputy Commissioner/Additional Deputy Commissioner / Dy. Collector / Ist Class Stipendiary Magistrate/Sub-Divisional Magistrate/ExtraAssistantCommissioner/TalukaMagistrate/ExecutiveMagistrate.
(ii) ChiefPresidencyMagistrate/AdditionalChiefPresidencyMagistrate/PresidencyMagistrate.
(iii) RevenueOfficersnotbelowtherankofTehsildar.
(iv) Sub-DivisionalOfficersoftheareawherethecandidateand/orhisfamilynormallyresides.
NOTE: ST candidates belonging to Tamil Nadu State should submit caste certificate ONLY FROM THE REVENUEDIVISIONALOFFICER.
(FORM OF CERTIFICATE TO BEPRODUCED BY OTHER BACKWARD CLASSES APPLYING FOR APPOINTMENT TO POSTS UNDER THE GOVERNMENT OF INDIA)
ThisistocertifythatShri/Smt./Kumari__________________________________________________ son/daughterof__________________________________ofvillage/town__________________________in District/Division_______________intheState/UnionTerritory_________________________belongstothe ___________________CommunitywhichisrecognizedasabackwardclassundertheGovernmentofIndia, Ministry of Social Justice and Empowerment’s Resolution No. __________ _________________________ dated________________*.
Shri/Smt./Kumari_____________________________________and/orhis/herfamilyordinarilyreside(s)inthe ____________________District/Divisionofthe_______________State/UnionTerritory.Thisisalsotocertify thathe/shedoesnotbelongtothepersons/sections(CreamyLayer)mentionedinColumn3oftheSchedule to the Government of India, Department of Personnel & Training O.M. No. 36012/22/93-Estt (SCT) dated 8.9.1993**.
DistrictMagistrate:___________________________
DeputyCommissioneretc.:_____________________
Dated: Seal:
*TheauthorityissuingthecertificatemayhavetomentionthedetailsofResolutionofGovernmentofIndia,in whichthecasteofthecandidateismentionedasOBC. **Asamendedfromtimetotime.
Note:Theterm“Ordinarily”usedherewillhavethesamemeaningasinSection20oftheRepresentationof thePeopleAct,1950.
(Name&Addressoftheauthorityissuingthecertificate)
INCOME & ASSEST CERTIFICATE TO BE PRODUCED BY ECONOMICALLY WEAKER SECTIONS
CertificateNo._____________________________ Date_________________
This is to certify that Shri/Smt./Kumari _________________________________________ son/daughter/wife of __________________________________________ permanent resident of_______________________ Village/Street ______________________ Post Office __________ District _______________________intheState/UnionTerritory___________________PinCode______________ whose photograph is attested below belongs to Economically Weaker Sections, since the gross annual income*ofhis/her‘family’**isbelowRs.8Lakh(RupeesEightLakhonly)forthefinancialyear________. His/herfamilydoesnotownorpossessanyofthefollowingassets***:
I 5acresofagriculturallandandabove;
II Residentialflatof1000sq.ft.andabove;
III Residentialplotof100sq.yardsandaboveinnotifiedmunicipalities;
IV Residentialplotof200sq.yardsandaboveinareasotherthanthenotifiedmunicipalities.
2. Shri/Smt./Kumari ___________________________________ belongs to the __________ ____________________________castewhichisnotrecognizedasaScheduledCaste,ScheduledTribeand OtherBackwardClasses(CentralList).
*Note1:Incomecoveredallsourcesi.e.salary,agriculture,business,professionetc.
**Note 2: The term ‘Family’ for this purpose include the person, who seeks benefit of reservation, his/ her parentsandsiblingsbelowtheageof18yearsasalsohis/herspouseandchildrenbelowtheageof18years.
***Note3:Thepropertyheldbya“Family”indifferentlocationsordifferentplaces/citieshavebeenclubbed whileapplyingthelandorpropertyholdingtesttodetermineEWSstatus.
Form-V Certificate of Disability
(Incasesofamputationorcompletepermanentparalysisoflimbsordwarfismand incaseofblindness)
[Seerule18(1)]
(NameandAddressoftheMedicalAuthorityissuingtheCertificate)
Recent passportsize attested photograph (Showingface only)ofthe personwith disability
CertificateNo._____________
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 ___________________,whosephotographisaffixedabove,andamsatisfiedthat:
(A) he/sheisacaseof:
Locomotordisability
dwarfism
blindness
(Pleasetickasapplicable)
(B) thediagnosisinhis/hercaseis_______________________________________
(C) he/shehas________%(infigure)_____________________________percent(inwords)permanent locomotor disability/dwarfism/blindness in relation to his/her ____________________ (part of body) as per guidelines(numberanddateofissueoftheguidelinestobespecified).
2. Theapplicanthassubmittedthefollowingdocumentasproofofresidence:NatureofDocument DateofIssue Detailsofauthorityissuing certificate
(SignatureandSealofAuthorisedSignatoryof notifiedMedicalAuthority)
Signature/thumbimpressionoftheperson inwhosefavourcertificateofdisabilityisissued
Annexure-E
Form – VII Certificate of Disability (IncasesotherthanthosementionedinFormsV) (NameandAddressoftheMedicalAuthorityissuingtheCertificate)(Seerule18(1))
CertificateNo.____________
Recentpassport sizeattested photograph (Showingface only)oftheperson withdisability
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 beenevaluatedasperguidelines(………..numberanddateofissueoftheguidelinestobespecified)andis shownagainsttherelevantdisabilityinthetablebelow:
shallbevalidtill(DD/MM/YY)__________________.
@-eg.Left/Right/botharms/legs
#-eg.Singleeye/botheyes
€-eg.Left/Right/bothears
4. Theapplicanthassubmittedthefollowingdocumentasproofofresidence:
NatureofDocument
DateofIssue
Detailsofauthorityissuing certificate
(AuthorizedSignatoryofnotifiedMedicalAuthority) (NameandSeal)
Countersigned
{CountersignatureandsealoftheChiefMedicalOfficer/ MedicalSuperintendent/HeadofGovernmentHospital, IncasetheCertificateisissuedbyamedicalauthority whoisnotaGovernmentservant(withseal)}
Signature/thumbimpressionoftheperson inwhosefavourcertificateofdisabilityisissued
Note:IncasethiscertificateisissuedbyamedicalauthoritywhoisnotaGovernmentservant,itshallbevalid onlyifcountersignedbytheChiefMedicalOfficeroftheDistrict
Certificate regarding Physical Limitation in an examinee to write
Thisistocertifythat,IhaveexaminedMr./Ms/Mrs._______________________________(nameof the candidate with disability), a person with ____________________________________ (nature and percentageofdisabilityasmentionedinthecertificateofdisability)S/o/D/o___________________________ aresidentof____________________________________________________________(Village/District/State) and to state that he/shehas physical limitation whichhampers his/her writing capabilities owning to his/her disability.
Signature ChiefMedicalOfficer/CivilSurgeon/ MedicalSuperintendentofaGovernmentHealthCareInstitution Name&Designation NameofGovernmentHospital/HealthCareCentrewithSeal
Place:_______________
Date :_______________
Note: Certificate should be given by a specialist of the relevant stream/disability (e.g. Visual impairmentOphthalmologist,Locomotordisability-Orthopaedicspecialist/PMR)
Letter of Undertaking for Using Own Scribe
I_______________________________________________,acandidatewith__________________ __________________________(nameofthedisability)appearingforthe____________________________ _________________________(nameoftheexamination)bearingRollNo._________________________at _______________________________(nameofthecentre)intheDistrict____________________________ _________________________(nameoftheState/UT).Myqualificationis__________________________ ____________________.
Idoherebystatethat_______________________________________(nameofthescribe)willprovide theserviceofscribe/reader/labassistantfortheundersignedfortakingtheaforesaidexamination.
Idoherebyundertakethathis/herqualificationis______________________________.Incase, subsequentlyitisfoundthathis/herqualificationisnotasdeclaredbytheundersignedandisbeyondmy qualification,Ishallforfeitmyrighttothepostandclaimsrelatingthereto.
Place:______________
Date:_______________
(SignatureofthecandidatewithDisability)