issue of general caste certificates - punjab, india · > z À w µ p î ì í ó w p ï } ( ó
TRANSCRIPT
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Last Rev: Aug 2017 Page 1 of 7
Department of Welfare of SC / BC Issuance of Caste Certificate (General)
Official Use Only ਕੇਵਲ ਦਫਤਰੀ ਵਰਤ ਲਈ nko Nh n?; ;oft; e'v /RTS Service Code: 105
Application Number / ਅਰਜੀ ਨੰਬਰ : Date of Application / ਅਰਜੀ ਦੀ ਿਮਤੀ
Name of Block & Tehsil /ਬਲਾਕ /ਤਿਹਸੀਲ ਦਾ ਨ Fields marked with asterisk (*) are mandatory/ ਿਜਹੜ ੇਫੀਲਡ ਤ ੇਤਾਰਾ fuzB (*) ਲਿਗਆ ਹ,ੈ T[j ਭਰਨ ਜਰੂਰੀ ਹਨ Part – 1 Personal Details / ਿਵਅਕਤੀਗਤ ਵਰੇਵਾ
Details of Person Filling the Application Form / noIh ਫਾਰਮ ਭਰਨ ਵਾਲੇ ਿਵਅਕਤੀ ਦਾ ਵੇਰਵਾ
Self Attested Photo of Beneficiary
bkGgkso dh ;t?^s;dheP[dk
c'N'
1. Name / ਿਬਨਕਾਰ ਦਾ ਨ
2. Address / ਿਬਨਕਾਰ ਦਾ ਪਤਾ
3. Relation with Beneficiary / ਿਬਨਕਾਰ ਦਾ ਲਾਭਪਾਤਰ
ਨਾਲ ਿਰਸ਼ਤਾ
Personal Data of Beneficiary / ਲਾਭਪਾਤਰ ਦਾ ਿਵਅਕਤੀਗਤ ਡਾਟਾ 4. Name / ਨ *
5. Gender / ਿਲੰਗ * Male / ਪੁਰਸ਼ Female / ਔਰਤ 6. Date of birth / ਜਨਮ ਿਮਤੀ 7. Age (if Date of birth not known)/
ਉਮਰ (ਜੇਕਰ ਜਨਮ ਿਮਤੀ ਨਹੀ ਪਤਾ)
8. Place of Birth / ਜਨਮ ਅਸਥਾਨ
9. Father's Name / ਿਪਤਾ ਦਾ ਨ *
10. Mother's Name / ਮਾਤਾ ਦਾ ਨ
11. Address / ਪਤਾ *
PIN Code / ਿਪੰਨ ਕੋਡ District / ਿਜ਼ਲਾ *
12. Marital Status / ਿਵਆਹ ;fEsh 13. Spouse Name / ਪਤੀ / ਪਤਨੀ ਦਾ ਨ
14. Email ID / ਈਮੇਲ ਆਈ ਡੀ 15. Contact Phone Number /ਸੰਪਰਕ
ਲਈ ਫੋਨ ਨੰਬਰ *
16. Voter ID Card Number / ਵੋਟਰ ਆਈ ਡੀ ਕਾਰਡ
ਨੰਬਰ
17. Aadhaar Number (UID) / nkXko ਨੰਬਰ (ਯੂ ਆਈ
ਡੀ)
Aadhaar Enrollment Number (if Aadhaar not issued)/ nkXko ਇਨਰੋਲਮਟ
ਨੰਬਰ (ਜੇਕਰ nkXko ਨੰਬਰ ਜਾਰੀ ਨਹ ਹੋਇਆ)
Part – 2 Service Details / ਸਵੇਾ ਦਾ ਵਰੇਵਾ
Application Details / noIh ਦਾ ਵਰੇਵਾ
18. Mode of Delivery of Service/ ਸਵੇਾ ਦੀ ਅਦਾਇਗੀ ਦਾ ਤਰੀਕਾ *
□ Sewa Kendra / ਸੇਵਾ ਕਦਰ
□ By Post/ ਡਾਕ ਦਆੁਰਾ
19. Application processing Office / ਅਰਜੀ ਕਾਰਵਾਈ ਦਫ਼ਤਰ Service Details / ਸਵੇਾ ਦਾ ਵਰੇਵਾ
20. Caste belongs to/;pzXs iksh
21. Reason for the Issuance of Caste Certificate/iksh ;oNhfce/N ikoh eoB bJh ekoD
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Part -3 List of Required Documents / ਜ਼ਰੂਰੀ ਦਸਤਾਵੇਜ ਦੀ ਸੂਚੀ . Please tick (√) the document attached / ਿਕਰਪਾ ਕਰਕੇ ਨੱਥੀ ਦਸਤਾਵੇਜ ਨੰੂ ਿਟੱਕ (√) ਕਰੋ
1 Report from concerned Patwari & Nambardar / Sarpanch / M.C.
;pzXs gNtkoh$Bzpodko$;ogzu$n?wH;h s'A fog'N
Mandatory
2 Self Declaration from Applicant
fpB?eko s'A ;t?̂ x'PDk gZso
Mandatory
3. Any Two Residence Proof – Voter Card / Driving License / Electricity Bill.
e'Jh th d' fojkfJPh d/ go{c t'No ekov$vokfJftzr
bkfJ;?A;$fpibh fpb
Mandatory
4. ID proof – Aadhar Card.
gfjukD gZso nkXko ekov
Mandatory
5. Attested Copy of Age Proof
T[wo d/ go{c dh s;dheP[dk ekgh
Mandatory
I confirm that I have been residing in India for at least 182 days in the preceding 12 months & information
(including biometrics) provided by me to the UIDAI is my own and is true, correct and accurate. I am aware that
my information including biometrics will be used for generation of Aadhaar and authentication. I understand that
my identity information (except core biometric) may be provided to an agency only with my consent during
authentication or as per the provisions of the Aadhaar Act. I have a right to access my identity information
(except core biometrics) following the procedure laid down by UIDAI. / w?A s;dhe eodk jK fe w?A fgSb/ 12
wjhfBnK ftZu xZN'FxZN 182 fdBQK s'A Gkos ftZu ofj fojk jK ns/ w/o/ tb'A :{ankJhaJ/avhankJh B{z fdZsh rJh
;{uBk (;w/s pkfJUw?fNqe) mhe tk do[Z;s j? . w?A fJ; sZE s'A ikD{ jK fe w/oh ;{uBk (;w/s pkfJUw?fNqe)
gqwkfDe ns/ nXko pDkT[D bJh tosh ikt/rh . w?B{z gsk j? fe gqwkfDesk d'okB w/oh fJj ;{uBk (f;tkJ/
e'o pkfJUw?fNqe d/), fe;/ th J/iz;h B{z w/oh ;fjwsh Bkb iK nXko n?eN d/ T[gpzXK nB[;ko jh gqdkB ehsh
ikt/rh . :{ankJhaJ/avhankJh tb'A fBoXkos gqfefonk ngDkT[D T[gozs w?B{z nkgDh fJ; ;{uBk (f;tkJ/ e'o
pkfJUw?fNqe d/) sZe gj[zu dk jZe jk;b j? ਅਤੇ ਮ ਸੱਚੇ ਿਦਲ ਿਬਆਨ ਕਰਦਾ / ਕਰਦੀ ਹਾਂ ਿਕ ਉਕੱਤ ਵੇਰਵੇ ਸਹੀ
ਹਨ ਅਤੇ ਕੋਈ ਜਾਣਕਾਰੀ ਛੁਪਾਉਣ / ਗਲਤ ਿਬਆਨੀ ਲਈ ਮ ਿਨੱਜੀ ਤੋਰ ਤੇ ਿਜੰਮੇਵਾਰ ਹੋਵਾਂਗਾ / ਹੋਵਾਂਗੀ
Citizen’s Signature / ਿਬਨੈਕਾਰ ਦੇ ਹਸਤਾਖਰ
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Self-Declaration$x'PDk gZso I _____________Son/Daughter/Wife of Sh________________Resident of________________________
District _____________, Punjab and hereby solemnly declare as under:-
w?A________________ g[Zso$g[Zsoh$gsBh ;qh________________ tk;h________________ fIbQk _____________,ਪੰਜਾਬ dk t;Bhe jK
ns/ j/m fby/ nB[;ko fpnkB eodk$eodh jK feL^
1. That I belong to______________ caste, My occupation is ________________ and no member of my family is
servicing in any Govt. Department My and my family incomes from all sources are Rs.________. This
income certificate is required to me or for my minor boy/girl_______________.
fJj fe w?A________________ iksh Bkb ;pzX oZydk$oZydh jK.w/ok feZsk ________________ j? ns/
w/o/ gfotko dk e'Jh th w?Apo ;oekoh ftGkr ftZu B"eoh BjhA eodk$eodh j?.w/oh ns/ w/o/ gfotko d/
;ko/ t;hfbnK s'A nkwdB________________ j?. fJj nkwdB ;oNhfce/N w?B{z y[Zd$nkgD/ Bkpkfbr
bVe/$bVeh bJh b'VhAdk j?.
2. That no certificate of this kind has been issued to me earlier, if issued then it is issued long time ago.
fJj fe w?B{z gfjbK nfijk e'Jh ;oNhfce/N ikoh BjhA ehsk frnk j?, i/eo ikoh ;[dk j? sK T[j pj[s
gfjbK dk j?.
3. That there is no any criminal case registered against me for which I have not deprived of from issuance of this
certificate. The information and the reports that are given for issuance of certificate is true and correct.
fJj fe w/o/ fto[ZX e'Jh th c"idkoh e/; BjhA uZb fojk j? fi; ftZu w?B{z fJ; ;oNhfce/N s'A tKM/ oZfynk
frnk j't/.w/o/ tZb'A fdZsh rJh doyk;s ns/ T[; ftZu doi fog'oNK T[es ;oNhfce/N ikoh eoB bJh ;jh
tk do[;s jB.
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Self- Declarant (x'PDk eosk)
Place$;EkB
Dated$fwsh
Verification$t?ohfce/PB
I hereby declare that the information given in above and attached documents is true and correct to the best of my knowledge and
belief and noting has been concealed therein. I know this fact very well that if any information given by me is found false the I shall
be liable for sentence under law and the benefits given to me on the basis of such information will be withdrawn summarily.
w?A fJZE/ fJj x';Dk eodk$eodh jK fe T[go'es fdZsh rJh ikDekoh ns/ Bkb BZEh d;skt/I w/oh ;wM nB[;ko ;jh tk do[Z;s j? ns/ fJ;
ftZu e[ZM th S[gkfJnk BjhA frnk j?.w?A fJBQK sZEK s'A ikD{ jK fe i/eo w/oh e'Jh th fdZsh rJh ;{uBK rbs fBebdh j? sK w?A ekB{zB ftZu
doi ;ik dk jZedko j'tKrk$j'tKrh ns/ w?B{z fJ; ;{uBk d/ nkXko s/ fdZs/ rJ/ bkG tkfg; b? bJ/ ikDr/.
Place$;EkB
Dated$fwsh
Self- Declarant (x'PDk eosk)
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Last Rev: Aug 2017 Page 5 of 7
Declaration form for issuance of General Caste Certificate
nkw iksh dk ;oNhfce/N ikoh eoB ;pzXh fpnkB gq'ckowk
I solemnly declare that I _______________________ Son/Daughter/Wife of Shri____________________
R/o___________________________________ belong to___________ caste and permanent resident of Punjab, this certificate is
required to me/my minor boy/girl ______________
w?A_____________________g[Zso$g[Zsoh$gsBh;qh_____________________ tk;h _____________________ Xow Bkb fpnkB ehsk j?
fe w?A _____________________ iks Bkb ;pzX oZydk$oZydh jK.gzikp dk gZe/$gZeh s"o s/ t;Bhe jK ns/ fJj ;oNhfce/N w?B{z nkgD/
bJh _____________________ ukjhdk j?.
Deponent/fpnkB eosk
Declaration from Nambardar/Sarpanch/MC/fpnkB Bzpodko$;ogzu$n?wH;hH
I ____________________Nambardar/Sarpanch/MC. R/O___________________________solemnly declare that
______________________Son/Daughter/Wife of Shri_________________________
R/o___________________________ is permanent resident of the given address and I personally know the declare.
w?A______________ Bzpodko$;ogzu$n?wH;hHtk;h ______________ Xow Bkb fpnkB eodk$eodh ______________ jK fe
g[Zso$g[Zsoh$gsBh ;qh tk;h______________ dk gZe/$gZeh s"o s/ t;Bhe j? ns/ w?A fpnkB eosk B{z iksh s"o s/ ikDdk$ikDdh jK.
Signature of Nambardar/Sarpanch/M.C.$j;skyoL Bzpodko$;ogzu$n?wH;hH
__________________________________________________________________________________
Sr. No.$bVh Bzpo___________ Dated$fwsh
Report Concerned Patwari:$fog'oN jbek gNtkoh
Signature: Circle Patwari$j;skyojbek gNtkoh
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dcso sfj;hbdko, ___________
Bzpo____________________ fwsh____________________
w[{b o{g ftZu ;/tk fty/ T[g wzvb w?fi;No/N______________ B{z G/i e/ p/Bsh ehsh iKdh j? fe gNtkoh jbek dh fog'oN ns/
;ogzu$Bzpodko$fwT{Af;gb e";bo dh s;dhe d/ nkXko s'A gqkoEh=_____________________ g[Zso$g[Zsoh$gsBh
;qh____________________tk;h____________________ sfj;hb____________________ fIbQk ________
B{z____________________ (iksh) dk ;oNhfce/N ikoh eoB dh f;ckfoP ehsh iKdh j?.
(sfj;hbdko)
___________________
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Feed Back Form/ ਫੀਡਬੈਕ ਫਾਰਮ
1. Is there any unnecessary information being asked in the Form?/ ਕੀ
eh ਫਾਰਮ ਿਵੱਚ ਕੋਈ ਵੀ ਬੇਲੋੜੀ ਜਾਣਕਾਰੀ ਮੰਗੀ ਗਈ ਹੈ < □ Yes / ਹ
□ No / ਨਹ
If Yes, Please specify the detail/ ਜੇਕਰ ਹ , sK ਵੇਰਵਾ fdT[
2. Is any vague information being asked in the form?/ ਕੀ ਫਾਰਮ ਿਵੱਚ eh
eh ਕੋਈ ਵੀ ਅਸਪ ਟ ਜਾਣਕਾਰੀ ਮੰਗੀ ਗਈ ਹੈ < □ Yes / ਹ
□ No / ਨਹ
If Yes, Please specify the details/ ਜੇਕਰ ਹ , sK ਵੇਰਵਾ fdT[
3. Is the space provided in the form sufficient for filling up the required information?/ ਕੀ ਫਾਰਮ ਿਵਚ ਮੁਹੱਈਆ EK b'VhAdh ਜਾਣਕਾਰੀ ਭਰਨ ਲਈ
ਕਾਫ਼ੀ ਹੈ
□ Yes / ਹ
□ No / ਨਹ
If No, Please specify the details/ ਜੇਕਰ ਨ , sK ਵੇਰਵਾ fdT[
4. Any other suggestion you may like to make, Please specify / ਕੋਈ ਹੋਰ ਸੁਝਾਅ ਦੇਣਾ ਚਾਹੰੁਦੇ ਹੋ ਤਾ ਵੇਰਵਾ fdT[