FORM-16 [rule 14]
EDUCATION Application Form No: ED-2020-00012056
Application Form for Verification of Nomadic Tribe (B) To, Member Secretary and Research Officer, District Caste Certificate Scrutiny Committee, Yavatmal. Dr. Babasaheb Ambedkar Social Justice Bhavan, Palaswadi Camp, Daravha Road, Dist. Yavatmal-445001
Subject :- Verification of Nomadic Tribe (B).
Respected Sir / Madam , I, the undersigned Kumar Kaustubh Ananta Shivarkar hereby request to verify my Caste Certificate of Nomadic Tribe (B). Following Information and documents are submitted here with in support of my caste claim.
APPLICANT INFORMATION:
Full Name of the Applicant: (As Mentioned in Caste Certificate)
Mr. Kumar Kaustubh Ananta Shivarkar
Marital Status : Single
Email ID : [email protected] Mobile No. : 9421806229
Aadhaar No.: 878619278296 Date Of Birth: 09/12/2002 Birth Place: Kumbha
Category : Nomadic Tribe (B) Caste : Bhoi (25) Applicants Caste Certificate No.: Caste Certificate Issuing Date: Caste Certificate Issuing District: 40942197303 24/08/2020 Yavatmal Designation of Caste Certificate issuing Authority: Sub Divisional Officer , Wani Name of the Document on which Caste Certificate is Obtained from Competent Authority: Applicant School LC/TC Father School LC/TC Grand Father School LC/TC Self Declaration Affidavit Caste Certificate of the Father Bonafide Certificate Ration Card Caste Validity Certificate in Blood Relative Copy of Kotwal Book Copy of Service Book Photo ID of Applicant
Purpose Of Scrutiny For Professional Education after Std. X / XII Mother Tongue: Marathi Regional Dialect: Marathi God/Goddess Name: Anganbai
Five different surnames of relatives or person from the same caste of the applicant:
Pachare Nagpure Dighore Dongare Karluke
APPLICANT ADDRESS
Correspondence Address : Permanent Address: Behind Mahavir Bhavan 201 Kumbha Tq.Maregaon Behind Mahavir Bhavan 201 Kumbha Tq.Maregaon
Country : India State : Maharashtra Country : India State : Maharashtra
District : Yavatmal Taluka : Maregaon District : Yavatmal Taluka : Maregaon
Pin code : 445303 Pin code : 445303
Since when applicant is residing at Correspondence address (YYYY) : 1900
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 Sainik Publik School 2009 2018 Nomadic Bhoi (25) -- Completed Education Wadki Dist Yavatmal Tribe (B) 2 Secondary Bharati Krishna 2018 2019 Nomadic Bhoi (25) -- Completed Education Vidyavihar Nagpur Tribe (B) 3 College St.Paul Junior 2019 2021 Nomadic Bhoi (25) -- In Progress Education College Nagpur Tribe (B) APPLICANT'S FAMILY DETAILS
Full Name of Applicant's Father: Ananta Kanhoba Shivarkar
Full Name of the Applicant's Grand Father: Kanhoba Sonba Shivarkar
Permanent Address of Father (If Father is not alive, then please mention full address of his last Residence) : Behind Mahavir Bhawan 201 Kumbha. Tq.Maregaon
Country : India State : Maharashtra
District : Yavatmal Taluka : Maregaon
Pin code : 445303
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 Primary Z.P.School Kumbha 1974 1979 Nomadic Bhoi (25) -- Completed Education Dist Yavatmal Tribe (B) 2 Secondary Bharat Vidya Mandir 1979 1985 Nomadic Bhoi (25) -- Completed Education Kumbha Dist Tribe (B) yavatmal 3 College Anand Niketan 1988 1991 Nomadic Bhoi (25) -- Completed Education College Warora Dist Tribe (B) Chandrapur
Applicant's Father Occupation: Contact Number: Inherited Profession of Family:
Service 9421806229 Agricultur
Office/ Business address with contact No: Adarsh Highschool Mardi Tq.Maregaon Dist Yavatmal 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 :
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:
Relation with Applicant:
Scrutiny Committee:
Purpose Of Scrutiny NILL When Verification took place? : Caste Validity Certificate No. of relative:
Date of issue of Caste Validity Certificate:
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 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
(b-6) Attested Xerox copy of identity card issued by the college
(b-7) If any of the above documents are not available, then attach other relevant documents (mention) (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: Yavatmal Applicant Signature
Date: 27-08-2020
Applicant's Father/Guardian Signature/Left Thumb Impression