FORM-16 [rule 14] EDUCATION Application Form No: ED-2021-00180891 Application Form for Verification of Other Backward Class To, Member Secretary and Research Officer, District Caste Certificate Scrutiny Committee, Amravati. B Wing, 1st Floor, Dr Babasaheb Ambedkar Social Justice Bhavan, Camp Road, Amravati-444606 Subject :- Verification of Other Backward Class. Respected Sir / Madam , I, the undersigned janhvi pramodrao deshmukh hereby request to verify my Caste Certificate of Other 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) janhvi pramodrao deshmukh Marital Status : Single Email ID : [email protected] Mobile No. : 8830416033 Aadhaar No.: 582461284742 Date Of Birth: 16/06/2003 Birth Place: AMRAVATI Category : Other Backward Class Caste : Kunbi (83) Applicants Caste Certificate No.: Caste Certificate Issuing Date: Caste Certificate Issuing District: MRC-81/3823 31/03/2018 Amravati Designation of Caste Certificate issuing Authority: Sub Divisional Officer , Tivsa-Bhatkuli Name of the Document on which Caste Certificate is Obtained from Competent Authority: Applicant School LC/TC Father School LC/TC Self Declaration Affidavit Caste Certificate of the Father Bonafide Certificate Caste Validity Certificate in Blood Relative Copy of Kotwal Book 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: MAHAKALI Five different surnames of relatives or person from the same caste of the applicant: DESHMUKH BHONGADE KALE DALVI PACHADE 2 : APPLICANT ADDRESS Correspondence Address : Permanent Address: AMAR CHAUK TIOSA TQ TIOSA, DIST AMRAVATI RAVI NAGAR MORSHI TQ MORSHI, DIST AMRAVATI Country : India State : Maharashtra Country : India State : Maharashtra District : Amravati Taluka : Teosa District : Amravati Taluka : Morshi Pin code : 444903 Pin code : 444905 Since when applicant is residing at Correspondence address (YYYY) : 1931 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 JIJAU PRIMARY 2009 2013 Other Kunbi (83) -- Completed Education ENGLISH SCHOOL Backward MORSHI, TQ Class MORSHI, DIST AMRAVATI 2 Secondary SHIVAJI HIGH 2013 2019 Other Kunbi (83) -- Completed Education SCHOOL MORSHI, Backward TQ MORSHI, DIST Class AMRAVATI Page 2 4 : APPLICANT'S FAMILY DETAILS Full Name of Applicant's Father: PRAMOD DEVIDAS DESHMUKH Full Name of the Applicant's Grand Father: DEVIDAS NARAYAN DESHMUKH Permanent Address of Father (If Father is not alive, then please mention full address of his last Residence) : RAVI NAGAR MORSHI. TQ MORSHI, DIST AMRAVATI Country : India State : Maharashtra District : Amravati Taluka : Morshi Pin code : 444905 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 PURV MADHYAMIK 1976 1982 Other Kunbi (83) -- Completed Education SCHOOL TIOSA, TQ Backward TIOSA, DIST Class AMRAVATI Applicant's Father Occupation: Contact Number: Inherited Profession of Family: Service 9960391014 SARVICE Office/ Business address with contact No: Z.P. WORKS SUB DIVISION MORSHI, TQ MORSHI, DIST AMRAVATI 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: KISHOR DEVIDAS DESHMUKH Relation with Applicant: Paternal uncle Address Of the Relative staying at Native Place: AMAR CHAUK TIOSA, TQ TIOSA, DIST AMRAVATI Contact No. of Relative: 8600203953 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: Relation with Applicant: Scrutiny Committee: Purpose Of Scrutiny NILL Page 4 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: DISTRICT CASTE CERTIFICATE SCRUTINY COMMITTEE, DISTRICT AMRAVATI Category: Other Backward Class Caste: Kunbi (83) Date of Application: 12/06/2013 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: Amravati Applicant Signature Date: 25-01-2021 Applicant's Father/Guardian Signature/Left Thumb Impression Page 7.