REVENUE DEPARTMENT, GOVT.

OF NCT OF DELHI
APPLICATION FORM SC/ST CERTIFICATE
BENEFICIARY DETAILS
1.

e-DistrictRegistration Number :

(For already Registered User- Not to be filled in by first time Applicants or those having Aadhaar number)
OR
2.
UID (AADHAAR) No
:
3.
4.
5.
6.
7.
8.
9.

Name of Beneficiary
Name of Father
Name of Mother
Name of Spouse
Gender
Date of Birth (DDMMYYYY)

: ___________________________________________
: ___________________________________________
: ___________________________________________
: ___________________________________________
:
Male
Female
Other
:

Mobile No. :

Beneficiary
color Passport Size
Photograph
Size 5 x 4.5 (Cm.)
Or
2 x 1.75 (Inch)

e-Mail ID :_________________@___________

(in case of minor, provide parents contact details)

10. Present Address (Address of Parents in case of Minor )

House Name/No :
Locality
:
Sub- division
:
State
:
PIN Code
:

______________________
______________________
______________________
______________________

Sub-Locality
Village/Town
District
Country

11. Whether the Present and Permanent Address is same :

:
:
:
:

______________________
______________________
______________________
_______________________

Yes

No

12. If No, Permanent Address (Address of Parents in case of Minor)

House Name/No :
Locality
:
Sub- division
:
State
:
PIN Code
:

______________________
______________________
______________________
______________________

Sub-Locality
Village/Town
District
Country

:
:
:
:

______________________
______________________
______________________
_______________________

DETAILS REQUIRED FOR ISSUANCE OF SC/ST CERTIFICATE

13. Applying for

Scheduled Caste

Scheduled Tribe

14. Whether any SC/ST certificate has been issued to any of the relatives from the paternal side?

Yes

(If the answer to the above question is No please go directly to S.No. 18.)
15. For SC/ST certificate mentioned in S.NO. 14

a.
b.
c.
d.
e.

Issued to : _____________________________
S.No. of the certificate: ______________________________
Date of Issuance of certificate: __________________________
Designation of the Issuing authority: ________________________
Relationship of the applicant with the certificate holder: _____________________
( a copy of the self-attested certificate should be attached)

No

16. Proof of Relationship of proposed beneficiary with the certificate holder as mentioned in S.No.15 (Attach Copy)
Aadhaar card

Passport

Birth Certificate

Voter ID Card

Ration Card

Driving License

PAN Card

Any Government ID containing

names of both the beneficiary
and certificate holder as family
member

Document No :
17. Please select any one applicable category out of a, b or c below:

a. Family is original Inhabitant of Delhi since prior to 1951 and your caste is notified as SC in Delhi
i. Name of Caste: ___________________
ii. S.No. of the caste in notification for Delhi: _________________________
b. Family has migrated to Delhi after 1951 but settled/ domiciled in Delhi and your caste is
notified as SC/ST from your state of migration as well as in Delhi( not valid for ST)
i. Name of the caste: ________________
ii. S.No. of the caste in notification for Delhi: ______________________
iii. Name of the State from which migrated: ______________________
iv. S.No. of the caste in the list in the state of origin:________________
v. Attach self-attested photocopy of at least one of the following documents:
Birth Certificate proving applicant was born in Delhi
Matriculation certificate/ mark sheet of a Delhi School for the applicant
Any proof of residence in Delhi since last 5 years
c. Family Migrated to Delhi after 1951 but caste is not notified as SC in Delhi
i. Name of caste: _______________________
ii. State from which migrated:__________________
iii. S.No. of the caste in the list in the state of origin______________________
18. If you have filled S.No. 15, 16 and 17 go directly to S.No. 19, then do not fill this column

When no Certificate has been issued to any of the paternal relatives, field verification shall be conducted to
ascertain case status. Please select one of the following:
a. For Original Delhi residents
I.
Name of the caste:_____________________
II.
S.No. of the caste in notification for Delhi:___________________
III.
Proof of Stay in Delhi prior to 1951:_______________________
b. For Migrant Population
I.
Name of the caste:_____________________
II.
S.No. of the caste in notification for Delhi :___________________
III.
State from which Migrated:_______________________________
IV.
S.No. of the caste in the State of origin:_____________________
V.
Proof of stay in state of origin prior to 1951
VI.
Attach Self attested copy of atleast one of the following documents:
Birth Certificate proving applicant was born in Delhi
Matriculation certificate/ mark sheet of a Delhi School for the applicant
Any proof of residence in Delhi since last 5 years

19. No certificate will be issued to an applicant who is migrant to Delhi and caste doesnot fall in Delhi State list and

no caste certificate has ever been issed to a paternal relative.

20. Purpose of obtaining Certificate :_______________________________________________________________
21. Religion (In case of SC)
Date:

DD MM 20YY

Place: ______________________

Hindu

Sikh

Signature of Beneficiary

Buddhist
:

(Parents Signature in case of minor)

22. Self-Declaration

I ________________________________________S/o/D/o Sh._______________________________
aged _______________R/o____________________________________________________________
Verify as Under:
I.
That the above contents are correct to the best of my knowledge and belief and nothing has been concealed
therein.
I further affirm thatII.
I am aware that in case the information furnished above is found to be incorrect, I shall be liable for prosecution
under section 177 & 191 of the Indian Penal Code, which stipulates as under:177. Furnishing False Information- whoever, being legally bound to furnish information on any subject to any
public servant, as such, furnishes, as true, information on the subject which he knows or has a reason to believe
to be false, shall be punished with simple imprisonment for a term which may extend to six months, or fine which
may extend to one thousand rupees, or with both;
Or, if the information which he is legally bound to give respects the commission of an offence, or is required for
the purpose of preventing the commission of an offence, or in order to the apprehension of an offender, with
imprisonment of either description for a term which may extend to two years, or with fine, or with both.

III.

Date:

191. Giving false evidence- Whoever being legally bound by an oath or by an express provision of law to state
the truth, or being bound by law to make a declaration upon any subject, makes any statement which is false,
and which he either knows or believes to be false or does not believe to be true, is said to give false evidence.
Providing any false evidance shall be punishable under section 193 of IPC, 1860 which provides imprisonment
for a term upto three years and fine.

DD MM 20YY

Place: ______________________

Signature of Beneficiary

(Parents Signature in case of minor)