Government of Odisha Next >

Revenue & Disaster Management Department Print Form

Annexure - II
FORM NO. - 1 ( See Rule - 4 )
Application Form for Issue of a Miscellaneous Certificate
R.I. Office

1. Name of the Applicant

2. Father's/Husband's Name
3. Address
(a) Permanent

(b) Present

4. Age (in years)

5. Type of certificate is required
Identity Nativity Legal Heir
( Identity/ Nativity/ Legal heir/ Caste/
Caste Income Resident
Income/ Resident/ Nationality/ Valuation/
Solvency/ Procession and any other certificate ) Nationality Valuation Solvency
Procession Other

6. Purpose for which the certificate is required

7. Particulars on the basis of which the

certificate is required

8. List of documents and affidavit. (1)

(where necessary)
(2)

(3)

Published on National Portal of India (india.gov.in)

 Home < Previous

9. DECLARATION:

I Sri/Kumari/Smt. son/daughter/wife of

Sri Resident of village

P.O. P.S in the district of

do hereby declare that the information and particulars stated above

are true to the best of my knowledge and belief and that they are exhaustive and I have not suppressed and
any fact in case it is detected later on that any of the facts stated above are wrong or that I have suppressed
some material facts I shall be liable for prosecution under the relevant law.

Place

Date
Signature of the Applicant

Published on National Portal of India (india.gov.in)