1 REVENUE DEPARTMENT, GOVT. OF NCT OF DELHI APPLICATION FORM – SC/ST CERTIFICATE BENEFICIARY DETAILS 1. e-DistrictRegistration Number : (For already Registered User- Not to be filled in by first time Applicants or those having Aadhaar number) OR 2. UID (AADHAAR) No : 3. Name of Beneficiary : ___________________________________________ 4. Name of Father : ___________________________________________ 5. Name of Mother : ___________________________________________ 6. Name of Spouse : ___________________________________________ 7. Gender : Male Female Other 8. Date of Birth (DDMMYYYY) : 9. Mobile No. : e-Mail ID :_________________@___________ (in case of minor, provide parents contact details) 10. Present Address (Address of Parents in case of Minor ) House Name/No : ______________________ Locality : ______________________ Sub- division : ______________________ State : ______________________ PIN Code : Sub-Locality : ______________________ Village/Town : ______________________ District : ______________________ Country : _______________________ 11. Whether the Present and Permanent Address is same : Yes No 12. If No, Permanent Address (Address of Parents in case of Minor) House Name/No : ______________________ Locality : ______________________ Sub- division : ______________________ State : ______________________ PIN Code : Sub-Locality : ______________________ Village/Town : ______________________ District : ______________________ Country : _______________________ DETAILS REQUIRED FOR ISSUANCE OF SC/ST CERTIFICATE 13. Applying for : Scheduled Caste Scheduled Tribe 14. Whether any SC/ST certificate has been issued to any of the relatives from the paternal side? Yes No (If the answer to the above question is ‘No’ please go directly to S.No. 18.) 15. For SC/ST certificate mentioned in S.NO. 14 a. Issued to : _____________________________ b. S.No. of the certificate: ______________________________ c. Date of Issuance of certificate: __________________________ d. Designation of the Issuing authority: ________________________ e. Relationship of the applicant with the certificate holder: _____________________ ( a copy of the self-attested certificate should be attached) Beneficiary color Passport Size Photograph Size – 5 x 4.5 (Cm.) Or 2 x 1.75 (Inch)
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REVENUE DEPARTMENT GOVT OF NCT OF DELHI ......1 REVENUE DEPARTMENT, GOVT.OF NCT OF DELHI APPLICATION FORM – SC/ST CERTIFICATE BENEFICIARY DETAILS 1. e-DistrictRegistration Number
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REVENUE DEPARTMENT, GOVT. OF NCT OF DELHI
APPLICATION FORM – SC/ST CERTIFICATE
BENEFICIARY DETAILS
1. e-DistrictRegistration Number :
(For already Registered User- Not to be filled in by first time Applicants or those having Aadhaar number)
OR
2. UID (AADHAAR) No :
3. Name of Beneficiary : ___________________________________________
4. Name of Father : ___________________________________________
5. Name of Mother : ___________________________________________
6. Name of Spouse : ___________________________________________
7. Gender : Male Female Other
8. Date of Birth (DDMMYYYY) :
9. Mobile No. : e-Mail ID :_________________@___________
(in case of minor, provide parents contact details)
10. Present Address (Address of Parents in case of Minor )
House Name/No : ______________________
Locality : ______________________
Sub- division : ______________________
State : ______________________
PIN Code :
Sub-Locality : ______________________
Village/Town : ______________________
District : ______________________
Country : _______________________
11. Whether the Present and Permanent Address is same : Yes No
12. If No, Permanent Address (Address of Parents in case of Minor)
House Name/No : ______________________
Locality : ______________________
Sub- division : ______________________
State : ______________________
PIN Code :
Sub-Locality : ______________________
Village/Town : ______________________
District : ______________________
Country : _______________________
DETAILS REQUIRED FOR ISSUANCE OF SC/ST CERTIFICATE
13. Applying for : Scheduled Caste Scheduled Tribe
14. Whether any SC/ST certificate has been issued to any of the relatives from the paternal side? Yes No
(If the answer to the above question is ‘No’ please go directly to S.No. 18.)
15. For SC/ST certificate mentioned in S.NO. 14
a. Issued to : _____________________________
b. S.No. of the certificate: ______________________________
c. Date of Issuance of certificate: __________________________
d. Designation of the Issuing authority: ________________________
e. Relationship of the applicant with the certificate holder: _____________________
( a copy of the self-attested certificate should be attached)
Beneficiary color Passport Size
Photograph
Size – 5 x 4.5 (Cm.)
Or
2 x 1.75 (Inch)
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16. Proof of Relationship of proposed beneficiary with the certificate holder as mentioned in S.No.15 (Attach Copy)
Aadhaar card Passport Birth Certificate
Voter ID Card Ration Card Any Government ID containing
names of both the beneficiary
and certificate holder as family
member
Driving License PAN Card
Document No :
17. Please select any one applicable category out of a, b or c below:
a. Family is original Inhabitant of Delhi since prior to 1951 and your caste is notified as SC in Delhi
i. Name of Caste: ___________________
ii. S.No. of the caste in notification for Delhi: _________________________
b. Family has migrated to Delhi after 1951 but settled/ domiciled in Delhi and your caste is
notified as SC/ST from your state of migration as well as in Delhi( not valid for ST)
i. Name of the caste: ________________
ii. S.No. of the caste in notification for Delhi: ______________________
iii. Name of the State from which migrated: ______________________
iv. S.No. of the caste in the list in the state of origin:________________
v. Attach self-attested photocopy of at least one of the following documents:
Birth Certificate proving applicant was born in Delhi
Matriculation certificate/ mark sheet of a Delhi School for the applicant
Any proof of residence in Delhi since last 5 years
c. Family Migrated to Delhi after 1951 but caste is not notified as SC in Delhi
i. Name of caste: _______________________
ii. State from which migrated:__________________
iii. S.No. of the caste in the list in the state of origin______________________
18. If you have filled S.No. 15, 16 and 17 go directly to S.No. 19, then do not fill this column
When no Certificate has been issued to any of the paternal relatives, field verification shall be conducted to
ascertain case status. Please select one of the following:
a. For Original Delhi residents
I. Name of the caste:_____________________
II. S.No. of the caste in notification for Delhi:___________________
III. Proof of Stay in Delhi prior to 1951:_______________________
b. For Migrant Population
I. Name of the caste:_____________________
II. S.No. of the caste in notification for Delhi :___________________
III. State from which Migrated:_______________________________
IV. S.No. of the caste in the State of origin:_____________________
V. Proof of stay in state of origin prior to 1951
VI. Attach Self attested copy of atleast one of the following documents:
Birth Certificate proving applicant was born in Delhi
Matriculation certificate/ mark sheet of a Delhi School for the applicant
Any proof of residence in Delhi since last 5 years
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19. No certificate will be issued to an applicant who is migrant to Delhi and caste doesnot fall in Delhi State list and
no caste certificate has ever been issed to a paternal relative.
20. Purpose of obtaining Certificate :_______________________________________________________________
21. Religion (In case of SC) Hindu Sikh Buddhist
Date:
Signature of Beneficiary :
(Parents Signature in case of minor) Place: ______________________
DD MM 20YY
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22. Self-Declaration
I ________________________________________S/o/D/o Sh._______________________________