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Self Declaration Form

This document is a self-declaration form for obtaining a Resident/Caste/Income/OBC/SEBC certificate in Odisha. The applicant provides personal details, family background, caste information, and income sources, affirming the truthfulness of the information under legal consequences. The declaration emphasizes the applicant's responsibility for the accuracy of the provided information and the potential consequences of false declarations.

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Sahadev Dey
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5K views1 page

Self Declaration Form

This document is a self-declaration form for obtaining a Resident/Caste/Income/OBC/SEBC certificate in Odisha. The applicant provides personal details, family background, caste information, and income sources, affirming the truthfulness of the information under legal consequences. The declaration emphasizes the applicant's responsibility for the accuracy of the provided information and the potential consequences of false declarations.

Uploaded by

Sahadev Dey
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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SELF DECLARATION FOR ISSUE

RESIDENT/CAST/INCOME/OBC/SEBC CERTIFICATE
(As per latter no RDM-GOEB-MISS-0043-2014-28781 DT-27-09-2014 OF Additional Chief secretary, Govt. of Odisha)

I…………………………………………………………………………………………………………aged about ……………… years, S/O, D/O,


W/O……………………………………………………………………………………. of village………………………………………………………………………
PS………………………………………., DIST………………………………………., ODISHA do hereby declare and state as follows.

1]. That my father/Grandfather……………………………………………………………. S/O……………………………………………………………….


Is/was R.T/CO R.T of village ……………………………………………………… under khata no ……………………. wherein our caste is
Recorded as ………………………………………. But subsequently our forefather changes their title
from…………………………………
To…………………………………. although we use the same caste.
2]. That, our caste is ………………………………. and family surname is ………………………………………… which comes under
Scheduled……………………………………………. as per ORISSA CASTE CERTIFICATE RULE,1980,8[I].

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 source is Rs………………………………. /i.e. from agriculture is Rs………………… /-

And from…………………………………………source is Rs…………………………. /-

5]. That, our caste is ………………………………… but surname is …………………………………. Which comes OBC/SEBC vide sl. No
………………………of central/state caste list.

6]. That, I here with furnish my self-declaration in support of my claim for issue of Resident/Caste/Income/OBC/SEBC
certificate in favor of……………………………………………………………. for the purpose of …………………………………………………………

I do hereby declare that the above information given by me in this application form and
its self-attested enclosures is true to the best of my knowledge and that 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 section 199 and 200 of the Indian Penal
Code in case of wrong declaration and information. Also, I am well aware of the fact that the certificate
shall be summarily cancelled and all the benefits availed by me shall be summarily withdrawn in case of
wrong declaration and information.

Date:

Place: Signature of the Applicant

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