Mobile No..........................................
Application/Declaration of the applicant for obtaining
Certificate of O.B.C (Other Backward Classes)
I ....................................................Son/Daughter/Wife of ........................................ …Resident
of village/town...............................................Post Office……………………….Tehsil……………...
Distt………….... of Himachal Pradesh declare as under:-
That I am belong to caste……………………OBC (Other Backward Classes), my family does not
belong to Creamy Layers as per latest notification and eligible to get certificate.
That my family income from all sources is Rs…………………….Per Annum
I solemnly affirm that the contents of this declaration are true and correct. I shall be liable For
prosecution if the facts given above are found incorrect.
Kindly issue OBC(other backward classes) Certificate in my favour.
Place:.................. Signature of the Applicant
Dated:..................
Attachment:
[Link] of Pariwar Register 2. Adhaar Card 3. Photo 4. Affidavit/Self Declaration 5. Pradhan/Patwari
report*
रिपोर्ट ग्राम पंचायत प्रधान/उप-प्रधान/पर्वािी :
दिन ांक:
प्रम णित ककय ज त है कक श्री/सश्र
ु ी/श्रीमती ...............................................................................
सुपुत्र/सुपुत्री/पत्नी ...............................................................ग ाँव............................................के स्थ यी/पुश्तैनी
ननव सी हैं, एवां ......................................ज नत से सांबांध रखते हैं | पांच यत स्तर पर इनक च ल-चलन नेक है,
आवेिक के आग्रह पर आवश्यक प्रम ि-पत्र ज री करने हेतु ररपोर्ट सेव में प्रस्तुत है |
हस्त क्षर
मोहर
AFFIDAVIT/ DECLARATION
I. ………………………………………..Son/Daughter/Wife of Sh………………………………
Resident of Village………………………………….. Post Office……………………………….
Tehsil………………………. Distt……………………of Himachal Pradesh, do hereby solemnly
and declare as under:
1. That I am belong to caste……………………OBC (Other Backward Classes), my family does
not belong to Creamy Layers as per latest notification and eligible to get certificate
2. That my family consists of……………. members. Detail of the members is as under:
Sr. Name Relationship Occupation
3. That my family income from all sources is Rs…………………….Per Annum.
4. That nothing regarding my Income has been concealed.
5. That I will be total responsible for statuary provision if my declaration is found wrong.
6. That the above statement is true and correct.
Place:
Date:
DEPONENT
Verification:
I the above named deponent further declare that the contents of this affidavit arc true and correct
to the best of knowledge and belief and nothing has been concealed therein.
Identified through Aadhar Card
No.
DEPONENT
