Form of Application for issue of Community, Nativity and Date of Birth Certificate relating to Scheduled
CASTE/ BACKWARD CLASS under Section 3(1) of the Act 16 of 1993
(Information to be furnished by the applicant himself supported by the documentary evidence)
The Mandal Revenue Officer, 
Shaikpet Mandal
Hyderabad District
    I am in need of Scheduled Caste/Backward Class Community certificate for me / for my son/daughter for which the 
    details are give below
1.    Name of the applicant (in block letter)
2.    Sex of the applicant
3.    a) Father Name
       b) Mother Name
4.    Present  postal address
5.    Place of permanent residence of the Certificate Seeker /
       is father / paternal Grand father as on the date of first
       Notification declaring the community as Scheduled Tribe,
       to which the certificate Seeker claims to belong
6.    Age, date of birth and place of birth
       (If date is known approximate year of birth)
7.    Place of ordinary residence (documents relating to
       house/land or other immovable property or Birth registration 
       certificate or ration card or school records may be furnished)
8.    If the applicant has been issued a community certificate
       in the past by any authority, a copy of such certificate
       should be furnished
9.    Community for which certificate is claimed
        (Including sub-tribe or sub-group)
10.   a) Community of the father
              (Including sub-tribe or sub-group)
b) Community of the Mother
(Including sub-tribe or sub-group)
11.   Whether the applicant is
         a) a natural born son or daughter of his/her parents
          b) adopted son/daughter of his/her parents


 I/We declare that the information furnished by me/us in the application is true and Correct, and the documents appended thereto are genuine and 
 the contents of the documents are true and correct and that if these are found to be untrue and incorrect I/We shall be liable for prosecution for 
 furnishing false and incorrect information / documents under section 10 of the Act No. 16 of 1993.

Signature of the Applicant          


Signature of the Parent/Guardian