Form of Caste Certificate

This is to Certify that claim of Sri/Smt/Kum._____________________________________________       S/o.D/o.W/o_______________________________________Village/town H No.___________________       ________________________________________________Taluk ______________________in the dist       ________________________________________of the state __________________________________       been verified as per the procedure laid down and he/she belongs to the _______________________       be/Backward classes under___________________________________________________________              *  The constitution (Schedule Castes) Order, 1950.              *  The constitution (Schedule Tribe) Order, 1950.       G.O Ms. No. 1793 Education date 23-9-70 as amended from time to time,       ( As amended by the Scheduled Castes and Scheduled Tribe Lists (Modification) order, 1956 the SC & ST       amended)       2. Sri/Smt/Kum.____________________________________________and his/her family ordinarily resides       in village/town H.No. ________________________________________________________________of       Dist/Divn. _____________________________________of the state of ___________________________       of place ____________________________________________state_____________________________

Signature of the Gazetted officer Date : Designation : Office Seal : NAME