FORM-16 [rule 14]
EDUCATION Application Form No: ED-2021-00208816
Application Form for Verification of Special Backward Class To, Member Secretary and Research Officer, District Caste Certificate Scrutiny Committee, Hingoli. Dr Babasaheb Ambedkar Social Jucstice Bhavan Office, Hingoli-431701
Subject :- Verification of Special Backward Class.
Respected Sir / Madam , I, the undersigned GONTALWAR MAROTI DASHRATH hereby request to verify my Caste Certificate of Special Backward Class. Following Information and documents are submitted here with in support of my caste claim.
1 : APPLICANT INFORMATION
Full Name of the Applicant: (As Mentioned in Caste Certificate)
GONTALWAR MAROTI DASHRATH
Marital Status : Single
Email ID : [email protected] Mobile No. : 9529501781
Aadhaar No.: 364166661712 Date Of Birth: 07/04/2004 Birth Place: BASMATH
Category : Special Backward Class Caste : Padmashali (3-9) Applicants Caste Certificate No.: Caste Certificate Issuing Date: Caste Certificate Issuing District: 41153065620 24/09/2018 Hingoli Designation of Caste Certificate issuing Authority: Sub Divisional Officer , Basmath Name of the Document on which Caste Certificate is Obtained from Competent Authority: Applicant School LC/TC Father School LC/TC Self Declaration Affidavit Bonafide Certificate Caste Validity Certificate in Blood Relative Photo ID of Applicant
Purpose Of Scrutiny For Professional Education after Std. X / XII
Page 1 Mother Tongue: Marathi Regional Dialect: HINDU God/Goddess Name: MAROTI
Five different surnames of relatives or person from the same caste of the applicant:
TALEWAR GUDEWAR MACHEWAR SHANKEWAR MAHAJAN
2 : APPLICANT ADDRESS
Correspondence Address : Permanent Address: VINKAR COLONY MONDHA ROAD BASMATH TQ VINKAR COLONY MONDHA ROAD BASMATH TQ BASMATH DIST HINGOLI BASMATH DIST HINGOLI
Country : India State : Maharashtra Country : India State : Maharashtra
District : Hingoli Taluka : Basmath District : Hingoli Taluka : Basmath
Pin code : 431512 Pin code : 431512
Since when applicant is residing at Correspondence address (YYYY) : 2000
3 : APPLICANT EDUCATION DETAILS
S Education Name of Duration of Duration of Applicant Caste (As Other Caste Status r. Educational Education Education Category Mentioned (As (Completed/ N Institute/ School From To In Mentioned In Progress) o /College Address Educational In with Telephone No. Certificate) Educational Certificate) 1 Primary JAWAHAR BALAK 2009 2016 Special Padmashali -- Completed Education MANDIR UCCH Backward (3-9) PRATHMIK SHALA Class BASMATH 2 Secondary BAHIRJI SMARAK 2016 2019 Special Padmashali -- Completed Education VIDYALAYA Backward (3-9) BASMATH Class
Page 2 4 : APPLICANT'S FAMILY DETAILS
Full Name of Applicant's Father: DASHRATH MAROTI GONTALWAR
Full Name of the Applicant's Grand Father: MAROTI LAXMAN GONTALWAR
Permanent Address of Father (If Father is not alive, then please mention full address of his last Residence) : VINKAR COLONY MONDHA ROAD BASMATH. TQ BASMATH DIST HINGOLI
Country : India State : Maharashtra
District : Hingoli Taluka : Basmath
Pin code : 431512
Is Applicant's Father Literate?: Yes No
S Education Name of Duration of Duration of Applicant Caste Other Caste Status r. Educational Education Education Category (Completed/ N Institute/ School From To In Progress) o /College Address with Telephone No. 1 Secondary BAHIRJI SMARAK 1990 1991 Special Padmashali -- Completed Education VIDYALAYA Backward (3-9) BASMATH Class
Applicant's Father Occupation: Contact Number: Inherited Profession of Family:
LABOUR 9529501781 LABOUR
Office/ Business address with contact No: VINKAR COLONY MONDHA ROAD BASMATH
Page 3 5 : FAMILY MIGRATION DETAILS
State Migration
Is Applicant/Applicant's Family migrated to Maharashtra State? Yes No
From Which State? : Migration Year? :
Reason For Migration? :
Native Place Migration
Is Applicant/ Applicant's Family left the native place? Yes No
Who Left the place? : When left Native place (YYYY)?
Reason For Leaving : :
Whether Applicant/ Applicant's family holding house/land at native place? Yes No
Name of the relative who is residing at native Place currently:
Relation with Applicant:
Address Of the Relative staying at Native Place:
Contact No. of Relative: Email Address of Relative :
6 : FAMILY CASTE VALIDITY CERTIFICATE DETAILS
Whether the Caste Validity Certificate Scrutiny of any member of the family has done earlier?: Yes No
Name of Relative: GONTALWAR MAHIMA DASHRATH
Relation with Applicant: Sister
Scrutiny Committee: DISTRICT CASTE CERTIFICATE SCRUTINY COMMITTEE, DISTRICT HINGOLI
Purpose Of Scrutiny For Professional Education after Std. X / XII
Page 4 When Verification took place? : 2018 Caste Validity Certificate No. of relative: A1732654
Date of issue of Caste Validity Certificate: 16/06/2018
If Rejected give it's details: No
If applicant has applied for caste validity certificate before any committee in state of Maharashtra: Yes No
Name of Committee:
Category: Caste: Date of Application: Committee Decision: Valid Invalid Pending 7 : UPLOAD DOCUMENTS
WOULD YOU LIKE TO TAKE BENEFIT UNDER BLOOD RELATION FROM PATERNAL SIDE, IF ANY? Yes No
(A) Important Primary Document (Mandatory)-Upload Scan copy of Original Certificate/ Document or upload Self Attested copy in case of Xerox.
(a-1) Caste Certificate of Applicant
(a-2) FORM-17 - Affidavit to be produced alongwith Caste Scrutiny application Form
(a-3) Original Affidavit (In Specimen Form-3, [Rule - 4(1)] Affidavit of Claimant / Parent(s))
(a-4) Form-15A - Certificate to be given by Principal of the School/College
(a-5) Applicant Photo
(a-6) Applicant Signature
(a-7) Applicant's Parent Signature
(B) Important Secondary Documentary Evidence Proof Prior to deem Date only to Prove Caste Claim (Any one of the document can be upload)-Upload Scan copy of Original Certificate/ Document or upload Self Attested copy in case of Xerox.
(b-1) Certified Copy of Birth Certificate of Applicant's or Applicant's Father/Real Elder Uncle/Real Aunt/Grand Father (From Paternal side) issued by Competent Authority Prior to deem Date
(b-2) Certified Copy of Applicant's Primary School Leaving Certificate/School Register's Extract
(b-3) Certified Copy of Applicant's Father Primary School Leaving Certificate/School Register's Extract
(b-4) Certified Copy of School Leaving Certificate/School Register's Extract of Grand Father/Real Elder Uncle'/ Real Aunt (From Paternal Side)
(b-5) If relatives from Paternal side are illiterate, then Birth/Death Extracts of Father/Real Elder Uncle'/ Real Aunt/Grand Father (From Paternal Side) issued by Competent Authority (Village Extract No.14/Kotwar Book/Nationality Register)
(b-5) Any Other documents supporting Caste claim (Applicant can upload multiple VC under Blood Relation type.)
(b-6) Attested Xerox copy of identity card issued by the college
Page 5 (b-7) If any of the above documents are not available, then attach other relevant documents (mention)
Page 6 (b-8) Entry of caste mentioned in the documents of blood relatives from paternal side, registered before deemed date of respective caste category, e.g. sale or purchase deed of land, house or other immovable property, mortgage deed, agreement, inam sanad through which rights have been transferred
(b-9) Entry of caste of blood relatives from paternal side in National Registration Book mainly from Aurangabad Revenue Division.
(b-10) Documents related to Inam land available in the records of Directorate of Archives revealing the evidence of caste
(b-11) Entry of caste in the extract of Village Mutation Register, documents in the Format of `Ka`, `da`, `ee`, patra, entries of caste of blood relatives from paternal side mentioned in the documents of old Court proceedings
(b-12) Government and semi-Government certificates containing traditional Occupation of caste in the old Caste System in respect of ancestors in blood relations from paternal side, entered before deemed date.
(b-13) Old record wherein name of traditional occupation is mentioned as caste In lieu of surname.
(b-14) Sanad or Proceedings before deemed date, in which the tenant has been declared as the landlord, as per the provisions of the Maharashtra Tenancy and Agricultural Lands Act (LXVII of 1948) or any other law, revealing the entry of caste.
(b-15) Entries of caste in Census record entered before deemed date.
I am producing certified copy of above documents with my application. I declare on oath that the information furnished by me in this application is true and correct. I am aware that incomplete application will be rejected and responsibility of making fresh application will be of mine.
Place: Hingoli Applicant Signature
Date: 25-02-2021
Applicant's Father/Guardian Signature/Left Thumb Impression
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