Annexure V

ANNEXURE-V
FORMAT FOR SC/ST CERTIFICATE
The form of certificate to be produced by Scheduled Castes and Scheduled Tribes

candidates applying for appointment to posts under Government of India
This is to certify that
Shri/Shrimati/Kumari*___________________son/daughter of
____________________________village/town*_____________________
_______ of District/Division*_________________of the State/Union
Territory*____________________________ belongs to
the____________caste/Tribes* which is recognized as a Scheduled
Castes/Scheduled Tribes under:-
@The Constitution (Scheduled Castes) Order, 1950
@The Constitution (Scheduled Tribes) Order, 1950
@The Constitution (Scheduled Castes) Union Territories Order, 1951
@The Constitution (Scheduled Tribes) Union Territories Order, 1951
[As amended by the Scheduled Castes and Scheduled Tribes Lists (Modification)
order, 1956, the Bombay Reorganization Act, 1960 & the Punjab Reorganization Act,
1966, the State of Himachal Pradesh Act 1970, the North-Eastern Area
(Reorganization) Act, 1971; the Scheduled Castes and Scheduled Tribes Order
(Amendment) Act, 1976, the State of Mizoram Act, 1986, the State of Arunachal
Pradesh Act, 1986 and the Goa, Daman and Diu (Reorganisation) Act, 1987.]
@The Constitution (Jammu & Kashmir) Scheduled Castes Order, 1956
@The Constitution (Andaman and Nicobar Islands) Scheduled Tribes Order, 1959as
amended by the Scheduled Castes and Scheduled Tribes order (Amendment Act),
1976.
@The Constitution (Dadra and Nagar Haveli) Scheduled Castes order 1962.
@ @The Constitution (Dadra and Nagar Haveli) Scheduled Tribes Order 1962.
@The Constitution (Pondicherry) Scheduled Castes Order 1964
@The Constitution (Uttar Pradesh) Scheduled Tribes Order, 1967
@ @The Constitution (Goa, Daman & Diu) Scheduled Castes Order, 1968
@The Constitution (Goa, Daman & Diu) Scheduled Tribes Order 1968
@The Constitution (Nagaland) Scheduled Tribes Order, 1970
@The Constitution (Sikkim) Scheduled Castes Order 1978
@The Constitution (Sikkim) Scheduled Tribes Order 1978
@The Constitution (Jammu & Kashmir) Scheduled Tribes Order 1989
@The Constitution (SC) orders (Amendment) Act, 1990
@The Constitution (ST) orders (Amendment) Ordinance 1991
@The Constitution (ST) orders (Second Amendment) Act, 1991
@The Scheduled Castes and Schedules Tribes Orders (Amendment) Act, 2002
@The Constitution (Scheduled Castes) Order (Amendment) Act, 2002
@The Constitution (Scheduled Castes and Scheduled Tribes) Orders (Amendment)
Act, 2002
@The Constitution (Scheduled Castes) Orders (Second Amendment) Act, 2002
%2. Applicable in the case of Scheduled Castes/ Scheduled Tribes persons who
have migrated from one State/Union Territory Administration to another.
This certificate is issued on the basis of the Scheduled Castes/ Scheduled Tribes
certificate issued to Shri/Shrimati*_________________Father/Mother of
Shri/Srimati/Kumari*___________________of
village/town*_____________in District/Division*_____________of the
State/Union Territory*_________________ who belong to the Caste/Tribe*
which is recognized as a Scheduled Caste/Scheduled Tribe in the State/Union
Territory* of______________ issued by
the_______________date_____________
%3. Shri/Shrimati/Kumari*___________and/or* his/her family ordinarily

reside(s) in village/town*____________of_______________District/Division*
of the State/Union Territory* of ________________
Signature
**Designation________________
(with seal of office)
State/Union Territory
Place:
Date:
*Please delete the words which are not applicable
@Please quote specific presidential order
% Delete the paragraph which is not applicable.
NOTE: The term ordinarily reside(s) used here will have the same meaning as in
section 20 of the Representation of the People Act, 1950.
** List of authorities empowered to issue Scheduled Caste/Scheduled Tribe
Certificates:
(i) District Magistrate/Additional District Magistrate/Collector/ Deputy
Commissioner/Additional Deputy Commissioner/ Dy. Collector Ist Class Stipendiary
Magistrate/+Sub-Divisional Magistrate/Taluka Magistrate/Executive
Magistrate/Extra Assistant Commissioner. + (not below of the rank of 1 Class
Stipendiary Magistrate).
(ii) Chief Presidency Magistrate/Additional Chief Presidency
Magistrate/Presidency Magistrate.
(iii) Revenue Officers not below the rank of Tehsildar.
(iv) Sub-Divisional Officers of the area where the candidate and/or his family
normally resides.
(v) Administrator/ Secretary to Administrator/ Development Officer (Lakshadweep).
ANNEXURE-V
(FORMAT OF CERTIFICATE TO BE PRODUCED BY OTHER BACKWARD

CLASSES APPLYING FOR APPOINTMENT TO POSTS UNDER THE
GOVERNMENT OF INDIA)
This is to certify that Shri/Smt./Kumari_____________son/daughter

of___________of village/town_______________in
district/division___________________in the State/Union
Territory_______________belongs to the____________Community
which is recognized as a backward class under the Government of India,
Ministry of Social Justice and Empowerment’s resolution
No._______________ dated__________________*
Shri/Smt/Kumari___________________________and/or his/her
family ordinarily reside(s) in the_________________District/Division of
the_______________ State/Union Territory. This is also to certify that
he/she does not belong to the persons/sections (Creamy Layer) mentioned in
Column 3 of the Scheduled to the Government of India, Department of
Personnel & Training O.M. No. 36012/22/93-Estt (SCT) dated 8.9.1993. Ο.Μ.
No. 36033/3/2004-Estt. (Res) dated 9th March, 2004, O.M.
No.36033/3/2004-Estt. (Res) dated 14th October, 2008 and O.M. No.
36033/1/2013-Estt. (Res) dated 27th May, 2013**.
Dated:
Signature_____________
Designation___________
Seal
_____________________________________________________
*The authority issuing the certificate may have to mention the details of
Resolution of Government of India, in which the caste of the candidate's is
mentioned as OBC.
**- As amended from time to time.
$- List of Authorities empowered to issue Other Backward Classes certificate
will be the same as those empowered to issue Scheduled caste/ Scheduled Tribe
Certificates.
Note: The term "Ordinarily" used here will have the same meaning as in Section
20 of the Representation of the People Act, 1950.
ANNEXURE-V
Government of_________________
(Name & Address of the authority issuing the certificate)
INCOME & ASSET CERTIFICATE TO BE PRODUCED BY ECONOMICALLY

WEAKER SECTIONS
Certificate No. Date
VALID FOR THE YEAR_____________
This is to certify that Shri/Smt./Kumari____________ son/daughter/wife

of_____________permanent resident of_____________
Village/Street_________Post Office___________District________in the
state/Union Territory___________Pin Code________________ whose
photograph is attested below belongs to Economically Weaker Sections, since the gross
annual income of his/her 'family'* is below Rs. 8 Lakh (Rupees Eight Lakh only) for
the financial year______________. His/her family does not own or possess any of
the following assets **:
i. 5 acres of agricultural land and above;
ii. Residential flat of 1000 sq. ft. and above;
iii. Residential plot of 100 sq. yards and above in notified municipalities;
iv. Residential plot of 200 sq. yards and above in areas other than the notified
municipalities.
2. Shri/Smt/Kumari___________ belongs to the___________caste which is

not recognized as a Scheduled Caste, Scheduled Tribe and Other Backward Classes
(Central List).
Signature with seal of Office________

Name_______________
Designation___________
Passport size attested
__________________________________________________________
*Note 1: Income covered all sources i.e. salary, agriculture, business, profession etc.
2: The term 'Family" for this purpose include the person, who seeks benefit of
reservation, his/her parents and siblings below the age of 18 years as also his/her
spouse and children below the age of 18 years.
3: The property held by a "Family" in different locations or different places/cities have
been clubbed while applying the land or property holding test to determine EWS
status.

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ANNEXURE-V

FORMAT FOR SC/ST CERTIFICATE

The form of certificate to be produced by Scheduled Castes and Scheduled Tribes

%3. Shri/Shrimati/Kumari___________and/or his/her family ordinarily

(FORMAT OF CERTIFICATE TO BE PRODUCED BY OTHER BACKWARD

This is to certify that Shri/Smt./Kumari_____________son/daughter

INCOME & ASSET CERTIFICATE TO BE PRODUCED BY ECONOMICALLY

This is to certify that Shri/Smt./Kumari____________ son/daughter/wife

2. Shri/Smt/Kumari_ belongs to the_caste which is

Signature with seal of Office________

Passport size attested

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