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Annexure-XIV<br />

SPECIAL BACKWARD CLASS CERTIFICATE<br />

Photo of<br />

Applicant to be<br />

Attested by the<br />

Issuing authority<br />

ph<br />

This is to certified that Shri/Smt./Kumari______________son/daughter of Shri_______________resident of<br />

Village/Town ____________________________ Tehsil______________ District _________________ of the<br />

State/Union Territory ___________ belongs to the _________________________Caste. This caste has been<br />

declared as Special Backward Class by the State Govt. vide letter No.22/10/2013-1GS-III dated 28.2.2013.<br />

Shri/Smt./Kumari____________ and/or his/her family ordinarily reside(s) in Village/Town ____________ of<br />

Tehsil ________________ Distt. _______________ of the State/Union Territory____________.<br />

This is to certify that he/she does not belong to the person/section (Creamy layer) as per State Govt. letter<br />

No.1170-SW(1)-95 dated 07.06.1995, No.22/36/2000-3GS-III dated 09.08.2000 & No.213-SW(1)-2010 dated<br />

31.8.2010.<br />

This certificate has been issued keeping in view State Govt. instructions relating to this subject issued from<br />

time to time.<br />

Sr. No. ……………….<br />

Place …………………<br />

Dated …………………<br />

Signature with seal of issuing Authority<br />

Full Name …………………………….<br />

Designation …………………………...<br />

Address with Telephone No. with code …………….<br />

Issuing Authority : Tehsildar-cum-Executive Magistrate<br />

Naib Tehsildar-cum-Executive Magistrate<br />

Head of Department in case of Govt. employees<br />

….………………………………………………………………………………………..……………..…………<br />

The affidavit should be of the month of May 2014 or later.<br />

54

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