REVENUE DEPARTMENT, GOVT.

OF NCT OF DELHI
APPLICATION FORM OBC 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.
3.
4.
5.
6.
7.
8.

UID (AADHAAR) No
Name of Beneficiary
Name of Father
Name of Mother
Name of Spouse
Gender
Date of Birth

:
: ___________________________________________
: ___________________________________________
: ___________________________________________
: ___________________________________________
:
Male
Female
Other
:
DD
MM
YYYY

Present Address (Address of Parents in case of Minor )

House Name/No : ______________________
Locality
: ______________________
Sub- division
: ______________________
State
: ______________________
PIN Code
:
9. Whether the Present and Permanent Address is same :

Sub-Locality
Village/Town
District
Country

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

: ______________________
: ______________________
: ______________________
_______________________

Yes

No

10. if No, Permanent Address (Address of Parents in case of Minor and In case of married women, provide address before marriage of a women)

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

______________________
______________________
______________________
______________________

11. Mobile No. :

(in case of minor, provide parents contact details)

Sub-Locality
Village/Town
District
Country

:
:
:
:

______________________
______________________
______________________
_______________________

e-Mail ID :_________________@___________

DETAILS REQUIRED FOR ISSUANCE OF OBC CERTIFICATE

12. Applying For

:
Delhi
Central
13. If Central , Specify Name of State/UT: ____________________________
14. Name of Caste
:____________________________
15. Religion
:
Hindu
Muslim

District:_____________________
Sikh

Buddhist

16. Whether the beneficiary or his/her family resident of Delhi since 8th September1993?
Yes
(If yes, Please provide valid proof of residence document since 8th September 1993 or OBC certificate issued to
father/parental blood relative)
17. Duration of residence in Delhi
: ____________Year(s) _________Month(s)

No

18. Whether any of the paternal blood relations of the applicant possesses Other Backward class certificate?
a.

Yes

( Provide below details & attach an attested copy of Certificate issued to Father/Paternal blood relationship)

Name of Certificate Holder

Name of paternal blood

Relation with Applicant

APPLICATION FORM SURVIVING MEMBER CERTIFICATE

Certificate No.

Date of Issue

Issuing Authority Address

No

b.

(Provide one attestation from MP/MLA/Councillor and one from Gazetted Officer or two Verification from Gazetted officer)

1. Provide details of Caste verifying authority( MP/MLA/Councillor/Gazetted Officer )

i. Name of verifier
:_____________________
ii. Designation
: _____________________
iii. Name of Department :______________________
iv. Address
:______________________
_______________________
2. Provide details of Caste verifying authority ( Gazetted Officer )

i. Name of verifier
ii. Designation
iii. Name of Department
iv. Address

:_____________________
: _____________________
:______________________
:______________________
_______________________

v. ID Card (Please attach also) :______________________

vi. ID Card No
:
vii. Telephone No
:
viii. Mobile No
:
ix. e-Mail ID
: ________________@_______
v. ID Card (Please attach also) :______________________
vi. ID Card No
:
vii. Telephone No
:
viii. Mobile No
:
ix. e-Mail ID
: ________________@_______

19. Income Details of Parents (tick appropriate one)

Relative Name

Father

Mother

Service Type
Government Service
Armed Forces including Para-military Forces
Private Service
Business or Industry
Public Sector Undertaking
International Organizations (UN, UNICEF, WHO etc.)
Others
Father Service Details
a. Current Status:
(i)
on Job
(ii)
Retired
(iii)
(iv)

DD MM YYYY
(ii).a Date of Retirement
DD MM YYYY
Death
(iii).a Certificate Number ________ (iii).b Date of Death
Permanent Incapacitation (iv).a Certificate Number________ (iv).b Date of Incapacitation DD MM YYYY

b. Designation
: _____________________
d. Date of Joining : DD MM YYYY
c. Monthly Gross salary : ____________________
e. PAN No
:
Details of Employer :a. Name of Organization/Shop/Industry Name :__________________________________________________
b. Address of Organization:House Name/No : ______________________
Sub-Locality
: ______________________
Locality
: ______________________
Village/Town
: ______________________
Sub- division
: ______________________
District
: ______________________
State
: ______________________
Country
: _______________________
PIN Code
:
Mother Service Details
a. Current Status:
DD MM YYYY
(i)
on Job
(ii)
Retired
(ii).a Date of Retirement
DD MM YYYY
Death
(iii).a Certificate Number _________ (iii).b Date of Death
Permanent Incapacitation (iv).a Certificate Number________ (iv).b Date of Incapacitation DD MM YYYY
Designation
: _____________________
d. Date of Joining : DD MM YYYY

(iii)
(iv)

b.
c. Monthly Gross salary : ____________________
e. PAN No
:
Details of Employer :a. Name of Organization/Shop/Industry Name :__________________________________________________
b. Address of Organization:APPLICATION FORM SURVIVING MEMBER CERTIFICATE

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

______________________
______________________
______________________
______________________

Sub-Locality
Village/Town
District
Country

:
:
:
:

______________________
______________________
______________________
_______________________

20. Property Details : Owned by Father, Mother (Attach Property Documents)

i. Agricultural Land Holding
Particulars
Owner Name & Land location Address
Area of Land (In Sq. Meter)
Crop/Fruit
ii. Vacant land and/or Building Holding
Owner Name & Land/Building location Address
Area of Land/Building (In Sq. Meter)
Use of Land/Building

Irrigated Land

Un-irrigated Land

21. Income/Wealth Details : (Attach salary slip of last 3 months and IT Returns of last 3 Financial Year)
1

Annual family income from salary

Annual family income from Agriculture Land

Annual family income from Property

Annual family income from all other sources

22. Whether Tax Payer: (if yes, a copy of the last three years Income tax Return to be attached)
Yes
No
23. Whether covered in Wealth Tax Act (if so furnish details):
Yes
No
24. Identity Proof of Beneficiary(Please tick one, provide the document No. and attach the same )
Aadhaar Card
Passport
Letter (attested) from School Principal (for minor only)
Voter ID Card
Ration Card with Photograph
School ID Card (for minor only)
PAN Card
Driving License
Birth Certificate (for minor below 5 years only)
Any Govt. recognized document
Document No
25. Identity Proof of Parents ( in case parents applied on behalf of minor)(Please tick one, provide the document No. and attach the same )
Aadhaar Card
PAN Card
Ration Card with Photograph
Voter ID Card
Passport
Driving License
Any Govt. recognized document
Document No :
26. Present Address Proof of Beneficiary/Parents(in case of minor) (Please tick one, provide the document No. and attach the same )
AADHAR Card
Voter ID Card
Driving License
Passport
Ration Card
Electricity Bill DISCOM Name___________
.
Water Bill Utility Name _____________________
Gas
Bill
Comp Name _____________
1.
Telephone Bill Company name_______________
Any Govt. recognized document
91 No :
Rent Agreement (Registered)
Bank Passbook
Document
9
27. Permanent Address Proof of Beneficiary/Parents(in case of minor) (Please tick one, provide the document No. and attach the same )
AADHAR Card
Voter ID Card
Driving License
Passport
Ration Card
Electricity Bill DISCOM Name___________
.
Water Bill Utility Name _____________________
Gas
Bill
Comp Name _____________
1.
Telephone Bill Company name_______________
Any Govt. recognized document
91 No :
Rent Agreement (Registered)
Bank Passbook
Document

9
Declaration: I hereby solemnly affirm & declare that, all of the above furnished information, is true & correct to the best
of my knowledge. I am fully aware that furnishing incorrect or false or forged information will lead to punitive action
against me under the relevant statutory provisions.
Date:

DD MM 20YY

Place: ______________________

Signature of Beneficiary :
(Parents Signature in case of minor)

APPLICATION FORM SURVIVING MEMBER CERTIFICATE