For holding the meetings of the Scrutiny Committee, the Member-Convener shall issue notice to all the members along with the Agenda Note containing in brief the reason for such meeting and findings of the case(s) to be discussed at least a week before the scheduled date and time of the meeting and the place where the meeting will be held.
FORM—A [See Rule 3 of the Odisha Scheduled Castes, Scheduled Tribes and Backward Classes (Regulation of Issuance and Verification of Caste Certificates) Rules, 2019] APPLICATION FORM FOR OBTAINING ST OR SC OR SEBC OR OBC CERTIFICATE To The (Narrie of the Competent Authority) , Dist , Odisha.
Sir, A certificate as per the provisions of Rule 4 of the Odisha Scheduled Castes, Scheduled Tribes and Backward Classes (Regulation of Issuance and Verification of Caste Certificate) Rules, 2019 may please be issued. The detailed particulars about myself in support of my claim are furnished below, namely
1. Name
2. Parent's Name :
(a) Father
(b) Mother
3. PermanentAddress:
Vill/Town P.O.
P.S.
Tahasil Dist.
State Odisha 224 THE OD1SHA GAZETTE, OCTOBER 4, 2019/ASW1NA 12, 1941 PART111-A
4. Present Address :
_ P.O.
P.S.
Tahasil Dist.
State Odisha
5. Date of Birth
6. Sex
7. Nationality
8. Religion
9. Caste / Tribe/Community to which the applicant belongs
10. Name of the Sub-Caste / Sub-Tribe nts ofth epliath btinedacrfcate thenam e of the Caste or 11 Iathe aveoa ,e e arofi eentinedandthenuberofsuchcerfeandyissue TribeorCommuntymaybm m may be mentioned.
12. List of documents submitted
(a)
(b) . (c)
(d)
(e) Al DECLARATION I, Shri/Smt./Ku Son/ Daughter of Shri/Smt.
of Village , P.O. , P.S Dist in the State of Odisha do hereby -declare that the information or documents furnished above are true to the best of my knowledge and belief. I do hereby undertake that if subsequently in future, any information or document is found to be false, shall be liabie to be punished as per law and the benefits availed by me shall be recovered from me by the Government.
Place:
Date :
Signature of the Applicant Address :
PART III-A THE ODISHA GAZETTE, OCTOBER 4, 2019/ASWINA 12, 1941 225 FORM-B [See Rule 4 of the Odisha Scheduled Castes, Scheduled Tribes and Backward Classes (Regulation of Issuance and Verification of Caste Certificates) Rules, 2019] FORM OF CASTE CERTIFICATE GOVERNMENT OF ODISHA OFFICE OF THE District Certificate Case No Date This is to certify that , Son/Daughter of of Village/Town , P.O. , P.S.
, Tahasil in the district of 2 ;!, of ,the State of Odisha belongs to aste/Tribe/Community which is recognized as under the onstitution (Scheduled Castes) Order, 1950 or the Constitution (Scheduled Tribes) Order, 1950 as mended, from time to time or notified as SEBC by the Odisha State Commission for Backward lasses Act, 1993 or Other Backward Classes declared by Government of India in relation to the tate of Odisha.
Shri/Smt. /Miss and his/her family ordinarily reside(s) in the Village/Town , PS , Tahasil of the District of the State of Odisha.
Place:
Date:
Signature of the Competent Authority Designation (Seal) 226 THE ODISHA GAZETTE, OCTOBER 4, 2019/ASVJINA 12, 1941 PART III-A •••••••11•11.
FORM-C [ See Rule 6(2) of the Odisha Scheduled Castes, Scheduled Tribes and Backward Glasses (Regulation of Issuance and Verification of Caste Certificates) Rules, 2019] FORM OF PETITION FOR VERIFICATION OF GENUINENESS OF THE CASTE CERTIFICATE From To The Chairperson of the Scrutiny Committee Subject : Verification of Caste Certificate of Shri/Smt./Miss Sir, In inviting a reference to the subject noted above,I am to state the following regarding the Caste Certificate of Shri/Smt./Miss 1: That Shri/Smt./Miss is the son/daughter of , Vill. ,P.O ,P.S Tahasil , Dist and (in case of married woman) She is the wife of Vill , P.O , Tahasil , P.S , Dist.
2. That though he/she belongs to Caste / Community/ Tribe as evident from records (copies of records enclosed) his/her Caste/Community has been mentioned as in his/her Caste Certificates.
3. That,- the Caste Certificate(s) have been issued by the Authority/Authorities as detailed below :— Designation of Certificate The Address Purpose for Name of the If the the issuing No.& in which which issued Caste/ certificate Authority/ Date issued (Son/ as mentioned 'Community/ is valid or Authorities Daughter/ in the Tribe & cancelled (Tahasildar/ Wife of. , certificate Category (ST/ Sub-Collector/ VIII , (Education / . SC/OBC/ ADM/ P.O. , Service) SEBC) Collector) Tahasil. , mentioned in P.S. , the certificate Dist. ) (I) (ii) (iii) (iv) (v) (vi)
4. That, on the basis of the Caste Certificate he/she has availed reservation benefits as a ST/ SC/OBC/SEBC candidate as detailed below :—
(i) Educational benefits (details) :
(ii) In appointment to Public Service (details) :
PART III-A THE ODISHA GAZETTE, OCTOBER 4, 2019/ASW INA 12, 1941
(iii) In promotion in Public Service (details):
(iv) In Election to Public Posts as Public Representatives (details) :
(v) Purchase of land from SC/ST (details) :
The copies of relevant documents are attached herewith.
Taking into consideration the above facts, you are requested to make an enquiry for verifi of the genuineness of the Caste Certificate produced by the applicant cation I / We assure you, we will co-operate with the process of enquiry as and when called for ie Scrutiny Committee in this case for which my/our contact details are furnishe by d below : — (a) Name / Designation of the Complainant
(b) Office / Organigation
(c) Contact Address
(d) Phone / Mobile No.
(e) ID Proof (Copy of Voter Identity Card /Aadhaar Number/pAN Card / Passport) Yours faithfully, FORM-D [See Rule 7(22) of the Odisha Scheduled Castes, Scheduled Tribes and Backward Classes (Regulation utlssuance and Verification of Caste Certificates) Rules, 2019] VALIDITY CERTIFICATE No: FCC / Date This is to certify that the Caste/Tribe/Community Certificate issued to ....................................
, Son/Daughter of .ge/Town of,..
sil ,PO , PS in the district of I -Iie Tahasildar/Additional Tahasildar of the State of Odisha ng in g to in the district of .... . ........................ . ..... as dt (ST/SC/0E3C/SEBC) Community vide Misc. Case of Tahasil, after due Place :
Date :
Member-Convener, SLSC ................................
0/o the RDC, (CD/ND/SD) ...............................
(Seal) By order of the Governor [ ILLEGIBLE ] Principal Secretary to Government 227 (Name & designation of the Complainant) i:tiiry vide SLSC (FCC) Case No .1 / is found to be valid one.
Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Page 11