Format For No Govt. Job in The Family: Annexure - I

ANNEXURE –I
Format for No Govt. Job in the family
I..........................................,Son/Daughter of.............................aged………...year, R/o …………………

…………………………………………………………. District ………………, do hereby submit the
following information for claiming weightage under
the Socio-economic criteria namely:-
(1) That I have to apply for the post advertised by LUVAS against Category No _____Advt.
No. 01/2023 Dated.........................
(2 That my PPP No. is _____________ Aadhaar No. _______________ /PAN Card No./Voter ID No. (if
any) is _____________
(3) As per Govt. instructions, an applicant shall be entitled to 5% weightage provided that—
neither he himself nor any person from amongst the applicant’s family is/was or has
been a regular employee in any Department/Board/ Corporation/Company/Statutory
Body/Commission/Authority of Haryana Government or any other State Government
or Government of India;
and
gross annual income of the family from all sources i.e., salary, agriculture, business,
profession etc. for the financial year prior to the year of application should be less than
one lakh eighty thousand rupees (1,80,000/-)only.
The definition of Family for the purpose of Socio-Economic Criteria—

(i) male applicant means the applicant himself, his father, mother, wife, unmarried
brother(s) and son(s);
(ii) female unmarried applicant means the applicant herself, her father, mother and
unmarried brother(s);
(iii) female married applicant means the applicant herself, her husband, father-in-law,
mother-in-law, unmarried brother-in-law and son(s);
(iv) divorced female applicant means the applicant herself, her father, mother,
unmarried brother(s) and son(s);
(4) That any person among in candidate’s family in Government Job having separate PPP No/family
ID/ Ration Card will not be entitled to be awarded weighatge under Socio-Economic Criteria having no
Government Job.
(5) If a person himself or his family member is once selected/appointed with or without getting the
benefit of weightage, no other family member shall be considered for weightage for
selection/appointment to the same or any other post for which application has been submitted by any
member of the family.
(6) That no person as mentioned above had been in employment and gross income of family is less
than One Lakh Eighty Thousand Rupees only, therefore, the undersigned may be allotted weightage
under the socio-economic criteria having no Government Job.
(7) That I fully understand that the marks are given on the basis of information supplied by me and if
at any stage it is found that the information has been provided wrongly then not only my service can be
terminated on the ground of supply of wrong information even if without these marks or weightage also
my name would have figured within the select list/recommendation list. I also understand that criminal
action can be taken against me for providing wrong/false information.
(8) That the deponent shall not take advantage of the certificate(s) issued by the Competent
Authority if in meantime any other eligible person in my family obtains the benefits thereof in the
recruitment.
(9) Verified that the contents of all the above paras are true my knowledge and belief and nothing
has been concealed therein.
Place: - DEPONENT
Date:-
VERIFICATION: -
1. Report of Numberdar/MC:-
2. Report of Patwari:-
3. Verified by Tehsildar/Executive Magistrate
ANNEXURE –II
Experience Certificate
1. This is to certify that Shri/Smt/Ms/Kumari, ....................................... Son/Daughter/Wife

of Shri……………Resident of village/town………….……………Tehsil……………………
District………………………. of Haryana State/Union Territory has been serving as
………………………………(Complete nomenclature of the post) in the office of
………………………...(Department/Board/Corporation/Company/StatutoryBody/Commission
/Authority/Co-operative Banks etc. under Haryana Government.)
2. The period of engagement was from ……………………..to ................................... and

the completed ……….years and .......... months.
3. The EPF account no., if any, is/was ……………………….………………………….
4. The ESI account no, if any, is/was ……………………………………………………
Place: Signature with seal of Issuing Authority (Head of Office)

Date: Full Name
Designation
Address
Telephone no. with code
ANNEXURE –III
Certificate regarding physical limitations in an examinee to write

This is to certify that, I have examined Mr/Ms/Mrs (name of
the candidate with disability), a person with (nature and percentage of disability
as mentioned in the certificate of disability), S/o/D/o a resident of
Village/District/State) and to state that he/ she has physical limitation which
hampers his/ her writing capabilities owning to his/her disability.
Place:
Date:
Signature and seal of the Medical Authority
Name and Seal of Member Name and Seal of Member Name and Seal of the Chairperson
Name of Government Hospital/ Health Care Centre with Seal
Note: Certificate should be given by specialists of the relevant stream/ disability (e.g. Visual
impairment-Ophthalmologist, Locomotor disability-Orthopedic specialist/PMR).
Letter of Undertaking for Using Own Scribe
I, ______________, a candidate with (name of the

disability) appearing for the (name of the examination) bearing Roll
No. at
(name of the centre) in the District (name of the State). My
qualification is I do hereby state that (name of the
scribe) will provide the service of scribe/reader for the undersigned for taking the aforesaid
examination. I do hereby undertake that his/ her qualification is matric (in case of minimum
qualification of post is 10+2) or 10+2 (in case of minimum qualification of post is
Graduation/equivalent or higher). In case, subsequently it is found that his/her qualification is not as
declared by the undersigned and is beyond my qualification, I shall forfeit my right to the post and
claims relating thereto.
(Signature of the candidate with disability)
Place:
Date:
ANNEXURE-IV
(Declaration must be hand written by the candidate himself in Hindi as well as in English
and to be uploaded with application form).
I have read and understood the instructions mentioned above, I have also gone through
the particulars as mentioned in the form filled up by me/on my behalf and found the same correct
and in accordance with documents/my certificate issued by Board/College/University and all the
particulars are correct as per record. I understand that in the event of any of the particulars or
information above being found false or incorrect at any stage, my candidature shall be liable to be
rejected.
Candidate Signature
Annexure-V
Government of Haryana
(Name & Address of the authority issuing the certificate)
(ECONOMICALLY WEAKER SECTIONS)
INCOME AND ASSET CERTIFICATE
Certificate No..…………… Date:-
VALID FOR THE YEAR 2023-2024
This is to certify that Shri/Smt./Kumari ....................... son/daughter/wife

of…………..is permanent resident of………………………, village/Street ........................,
Post Office………………….., District……………….., Pin Code ......................... whose
photograph is affixed below and attested below belongs to Economically Weaker Section,
since the gross annual income* of his/her family** is below Rs. 6 lakh (Rupees Six Lakh
only) for the financial year 2022-2023.
It is further certified that 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 170 sq. yards and above in areas other than the notified
municipalities.
V. Total immovable assets owned are valued at Rs. One Crore or more.
2. Shri/Smt./Kumari ...................................belongs to the caste which is not recognized

as a Scheduled Caste, Backward Classes (Block-A) and Backward Classes (Block-B).
Signature with seal of Office

Name
Designation
Recent Passport
size attested
photograph of
the applicant
*Note 1: Income means income from all sources i.e. salary, agriculture, business,
profession etc.
**Note 2: The term “Family” for this purpose will include the person, who applies for
benefit of reservation, his/her parents, spouse as well as children and siblings
below the age of 18 years.
***Note 3: The property held by a “Family” in different locations or different
places/cities are to be clubbed while applying the land or property holding test to determine
EWS status.
Annexure-VI
Certificate No.
SPORTS GRADATION CERTIFICATE

Self-attested
1. Name of Sportsperson:……………………………………………… Photo
2. Aadhaar No.:………………………………………………………...
3. Mobile No.:………………………………………………………….
4. Name of District to which sportsperson belongs:…………………………………….
5. Domicile State:……………………………………………………………………….
6. Plays for (Name of State/Organization):……………………………………………..
7. Name of Sports Discipline:…………………………………………………………..
8. Best Sports Achievement:
i. Name of Tournament:………………………………………………………..
ii. Month & Year:……………………………………………………………….
iii. Venue of Tournament:……………………………………………………….
iv. Organizing Authority:……………………………………………………….
v. Tournament Type: Senior Junior
vi. Medal won (if any): Gold Silver Bronze
vii. Participation Level: 25% or more Less than 25%

(in case of team game only)
Date:- (Signature of Sportsperson)

…………………………………For official use only………………………………...
Checked. A copy of supporting documents (self-attested) in support of the claim is

retained in office.
Date:…………………… Granted Grade Sports Certificate.
District Sports & Youth Director, Sports*

Affairs Officer,……………………..
DEPARTMENT OF SPORTS & YOUTH AFFAIRS, HARYANA

#Required in case of Grade-A or Grade-B Sports Certificate only.
Annexure - XI
CHECK LIST
(The information in this Check List is to be furnished by the Employer in respect of the in-service
candidate for the last 10 years and in case the service period is less than 10 years then from the date
of joining)
Name of Employee : Designation of Employee:
Post Applied For : Advt. No. 1/2023
Year Overall Report about Report about Punishment Whether any
performance integrity work and awarded, if disciplinary / legal /
conduct any Vigilance
proceedings are
pending against the
official.
Does he/she fulfil the prescribed qualifications/experience required for the post?
Prescribed qualifications (Yes/No)
Prescribed experience (Yes/No)
It is also certified that the information furnished by the official in his application form is correct
as per his service record. Forwarded with the remarks that the facts stated in the above
application have been verified and found correct and this Institution/Organization has no
objection to the candidature of the applicant being considered for the post applied for.
Head of the Institution/Organization with Seal
(Name in block letters) _________________________

Designation___________________________________
Place: ___________
Date: ___________
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ANNEXURE –I

Format for No Govt. Job in the family

I..........................................,Son/Daughter of.............................aged………...year, R/o …………………

The definition of Family for the purpose of Socio-Economic Criteria—

1. This is to certify that Shri/Smt/Ms/Kumari, ....................................... Son/Daughter/Wife

2. The period of engagement was from ……………………..to ................................... and

3. The EPF account no., if any, is/was ……………………….………………………….

4. The ESI account no, if any, is/was ……………………………………………………

Place: Signature with seal of Issuing Authority (Head of Office)

Certificate regarding physical limitations in an examinee to write

Signature and seal of the Medical Authority

Name of Government Hospital/ Health Care Centre with Seal

Letter of Undertaking for Using Own Scribe

I, ______________, a candidate with (name of the

(Signature of the candidate with disability)

INCOME AND ASSET CERTIFICATE

Certificate No..…………… Date:-

VALID FOR THE YEAR 2023-2024

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

I. 5 acres of agricultural land and above;

2. Shri/Smt./Kumari ...................................belongs to the caste which is not recognized

Signature with seal of Office

SPORTS GRADATION CERTIFICATE

4. Name of District to which sportsperson belongs:…………………………………….

6. Plays for (Name of State/Organization):……………………………………………..

7. Name of Sports Discipline:…………………………………………………………..

8. Best Sports Achievement:

ii. Month & Year:……………………………………………………………….

iii. Venue of Tournament:……………………………………………………….

iv. Organizing Authority:……………………………………………………….

v. Tournament Type: Senior Junior

vi. Medal won (if any): Gold Silver Bronze

vii. Participation Level: 25% or more Less than 25%

Date:- (Signature of Sportsperson)

Checked. A copy of supporting documents (self-attested) in support of the claim is

Date:…………………… Granted Grade Sports Certificate.

District Sports & Youth Director, Sports*

DEPARTMENT OF SPORTS & YOUTH AFFAIRS, HARYANA

Head of the Institution/Organization with Seal

(Name in block letters) _________________________

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