FORM-16

( Rule No.14)
FOR GOVERNMENT/SEMI GOVERNMENT EMPLOYEES
SERVICE
APPOINTMENT/PROMOTION
APPOINTMENT/PROMOTION

SERVICE

Application Form for verification of Scheduled Caste/Scheduled Caste

converts to Buddhism/De-Notified Tribe (Vimukta Jati)/ Nomadic Tribe/Other
Backward Class/Special Backward Category certificate to be submitted to
Divisional
Caste Certificate Scrutiny Committee.
Affix
Passport size
Colour
Photo

To,
Member Seceretary and Research Officer,
Divisional Caste Scrutiny Committee, No.........
............................................
Sub :- Verification of Scheduled Caste/Scheduled Caste converts
to
Buddhism/De-Notified Tribe (Vimukta Jati)/
NomadicTribe/Other Backward
Class/Special Backward
Category Caste certificate
(Strike out whichever is not
applicable)
Sir,
I, the undersigned
Shri/Smt/Kum.........................................................presently
working/
have
been
appointed/to be promoted as..................at................................Department from
Date ............... under reserve Category of Scheduled Caste/Scheduled Caste converts to
Buddhism/De-Notified Tribe (Vimukta Jati)/Nomadic Tribe/Other Backward
Class/Special Backward Category. I hereby request to verify my caste certificate.
Following information and documents are submitted herewith in support of my caste
claim.

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(a) Full name of the Applicant (as

mentioned in caste certificate)and
present address
(b) In case of married female applicant,
name prior to marriage
(c) Mobile No.
(d) E-Mail
Caste/Sub Caste claimed by applicant
Applicant's a) Birth date
b) Birth place
Full Name of applicant's Father and
Permanent Address
(If Father is not alive please mention
full address of his last Residence.)
Full Name of applicant's Grand Father
(Father's Father)
Present occupation/service of
applicant's father with telephone
number and address
Father's Education
Inherited profession of Family
(a) Mother Tongue of Applicant
(b) Regional Dialect
(c) God/Godess
(d) Five Surnames of applicant's
Relative/persons from caste
Applicant's (a)Native Place

(b) If applicant has left Native place

Please specify when and who left
the
place and reason for leaving
(c) Since when applicant is residing at
present address.
(d) At present who is residing at native
place
Please give address and Telephone
No.
(e) Whether in possession of
House/land
at native place
Name of the competent authority from
whom caste certificate is obtainedI
And Certificate No. and Date

.........................................................................
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..................................Pin Code........................
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......................................................................Vil
lage/Town..............................................
Taluka...........................................................
District..........................................................
Pin Code.......................................................
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Village/Town...............................................
Post ....................................................
Taluka ....................................................
District
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Name of the document on which basis

caste certificate is obtained from
competent authority

...................................................................
...................................................................
...................................................................

13. Details of institution where applicant studied

Stage of Education
Name of Educational Duration of
Institute and Address Education (Year)

Caste mentioned in
educational institute's
record

(a) Primary
Education
(i.e. give sufficient
details from Std.l)
(b) Secondary
Education
(c) College
Education
14. If applicant's father is literate following information to be furnished
Stage of Education

Name of Educational
Institute and Address

Duration of
Education (Year)

Caste mentioned in
educational institute's
record

(a) Primary
Education
(i.e. give sufficient
details from Std.l)
(b) Secondary
Education
(c) College
Education
15. If applicant/applicant's family is migrated in Maharashtra from other State, following
information is to be furnished:Is applicant's family is migrated to .........................................................................
Maharashtra State? If yes, from which State .........................................................................
and when (Year)?
.........................................................................
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(a) Whether scrutiny of the caste

certificate
of any member of the
family has done
earlier? If yes
Name of family member, his relation
with applicant and why and when
scrutinized?

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(b) If Validity Certificate is received

give its Number and Date (enclose
attested copy)
(c) If rejected give its details
(a) If applicant has applied for caste
certificate before any committee in
the state.
If yes, (b) which committee
(c) For which Caste
(d) Date of application
(e) Committee's decision
Applicant's present employment details
(a) Name and address of the office
(b) Date of appointment, if appointed.
(c) Purpose of scrutiny

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Yes/No
.....................................................................
.....................................................................
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Valid/Invalid
.....................................................................
.....................................................................
.....................................................................
.....................................................................
For promotion/new appointment in reserved
category
(Strike out which is not applicable)

Documents to be attached with application

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Following documents are attached only as per the sequence.

(A)

Important Primary Documentary Evidence

(Strike out
applicable)

(a-1)
(a-2)
(a-3)
(a-4)

Original Caste Certificate of Applicant

Certified copy of Caste Certificate of Applicant
Certified Copy of Applicant's Birth Date
Certified Copy of Applicant's Primary School
Leaving Certificate/ School Register's Extract
Certified Copy of Applicant's Father Primary School
Leaving Certificate/ School Register's Extract
Certified Copy of School Leaving Certificate/
School Register's Extract of Grand Father/ Real
Elder Uncle/Real Aunt (From Paternal side)

Attachement Compulsary
Attachement Compulsary
Attached Yes/No
Attached Yes/No

(a-5)
(a-6)

(a-7)
(B)
(b-1)

whichever

Attached Yes/No
Attached Yes/No

Original Affidavit (in Specimen Form-3 and Form- Attached Yes/No

15A to be obtained from College/Caste Scrutiny
Committee Office)
Important Secondary Documentary Evidence * (If
above Primary Documentary Evidence are not
available)
If relatives from Paternal side are illiterate, then Attached Yes/No
Birth/Death extracts of Father/ Real Elder Uncle/

is

not

Real Aunt/ Grand Father (From Paternal side)

issued by Competent Authority (Village Extract
No.14 / Kotwar Book / Nationality Register)

(b-2)
(b-3)

OR
If Caste is not mentioned in above documents, then,
Revenue Record / old purchase/sale deed in which
caste is mentioned
Any other documents supporting caste claim
Attached Yes/No
If any of the above documents are not available, then ................................................
attach other relevent documents. (mention)
................................................
......

I am producing certified copy of above documents with my application. I declare

on oath that the information furnised by me in this application is true and correct. I am
aware that incomplete application will be rejected and responsibility of making fresh
application will be of mine.
Place :

Yours

Date
Applicant's signature.

CERTIFICATE OF APPOINTING AUTHORITY

This
is
to
certify
that
Shri/Smt.................................................................................................
is working/under consideration for appointment/promotion for the post of ..............., since
this post is reserved for Scheduled Caste/De-Notified Tribe (Vimukta Jati)/Nomadic
Tribe/Other Backward Class/Special Backward Category, the validity of his /her caste
certificate is necessary. So it is requested to verify his /her caste certificate. (Strike out
whichever is not applicable)
Place :
Date :

Sign & Stamp of the

Appointing Authority

Impoprtant Instructions:
(a) If Claim for Schedule Caste, Caste evidences should be prior to 10th August, 1950.
(b) If Claim for De-notified Tribes (Vimukta Jatis), Nomadic Tribes, Caste evidences
should be
prior to 21st November, 1961.
(c) If claim for Other Backward Class and Special Backward Category, Caste evidences
should
be prior to 13th October, 1967.
(d) In addition evidences of residents of above mentioned period is essential for
applicant who
has migrated in Maharashtra form other State.
(e) Migrants from other state to Maharashtra after above mentioned period whose Caste
Certificate is in "Migrants" format should not apply to committee.

FORM 16-A
(Rule No. 14)
For Government / Semi Government Employee
Affidavit to be submitted with application of Caste Certificate Verification
I Shri / Smt. --------------------------------------------------------------age ------------- year,
Occupation----------------------, residing at -------------------------------------------------------,
hearby solemnly affirm today dated ------------------ that caste certificate
Number-------------------------------dated----------- given by Tahasildar and Execiutive
Magistrate/Deputy Collector/Sub Divisional Officer---------------- District is submited for
the Scrutiny.
Validity Certificate is required for my Appointment/Promotion in reserved
category.
The documents and proofs attached with the application Form are obtained by me
from Competent Authority. These documents are true and correct and obtained by
followig proper procedure. No alteration / correction / change are made in these
documents. I affirm hereby that these documents are not duplicate or bogus.
*Caste Certificate of any relative from my paternal side was not invalidate by the
Scrutiny Committee.
*And it is not a case that I applied before any Caste Certificate Scrutiny
Committee in Maharashtra and my caste certificate is invalidated.
I will be resposible, if the documents and proofs attached with the application
form are found to be incorrect or bogus, and I am aware that I will be libale for
punishment under provision of Indian Penal Code.
I declare that the above mention information is true and correct, hence this
affidavit.

Place :Date:-

Signature of the Declarant

(*Delete which is not applicable)

FORM 3
[rule 4(1), 14]
AFFIDAVIT OF CLAIMANT/PARENT(S)
(Order 18, rule 4 of the Code of Civil Procedure,1908)
1.
I,...........................................,son/daughter
of
Shri/Smt................................,
aged
.........
years,
occupation................................,
residing
at
.............................
village/Town, ......................... Tahsil,................................ District, ................
State, hereby solemnly affirm as under :2.
I hereby give the genealogy tree of my family and relatives, which is
as under-

3.
Other relevant submissions to be made or any essential explanation to
be made, in support of Caste/Tribe claim, including the sociological,
anthropological and ethnological (anthropological moorings and
ethnological kinship), genetical traits, of the Caste/Tribes, if any;

To the best of my knowledge and belief the information given in the

application form and in this affidavit is based on facts and is correct.

Place :
Date :
claimant)

Signature.......................................
(Name of the applicant/