FORM-16 [rule 14]

EDUCATION Application Form No: ED-2022-00663279

Application Form for Verification of Other Backward Class

To,
Member Secretary and Research Officer,
District Caste Certificate Scrutiny Committee,
Thane. Kokan Bhavan, 5th Floor, Room No 524,
CBD Belapur, Navi Mumbai-400614

Subject :- Verification of Other Backward Class.

Respected Sir / Madam ,

I, the undersigned SATYAM ARUN KHARUK hereby request to verify my Caste Certificate of
Other Backward Class. Following Information and documents are submitted here with in support of my
caste claim.

1 : APPLICANT INFORMATION
Full Name of the Applicant: (As Mentioned in Caste Certificate)

SATYAM ARUN KHARUK

Marital Status : Single

Email ID : [email protected] Mobile No. : 8898891800

Aadhaar No.: XXXXXXXX1284 Date Of Birth: 11/04/2004 Birth Place: CHAUDHARPADA

Category : Other Backward Class Caste : Agri (169)

Applicants Caste Certificate No.: Caste Certificate Issuing Date: Caste Certificate Issuing District:
4070/16 07/09/2016 Thane
Designation of Caste Certificate issuing Authority: Sub Divisional Officer , Kalyan
Name of the Document on which Caste Certificate is Obtained from Competent Authority:
Applicant School LC/TC Father School LC/TC

Purpose Of Scrutiny For Professional Education after Std. X / XII

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Mother Tongue: Marathi Regional Dialect: MARATHI God/Goddess Name: KHANDOBA

Five different surnames of relatives or person from the same caste of the applicant:

BHOIR PATIL CHAUDHARI MHATRE BHANDARI

2 : APPLICANT ADDRESS
Correspondence Address : Permanent Address:
UMBARDE GAON NEAR HANUMAN MANDIR UMBARDE GAON NEAR HANUMAN MANDIR
ADHARWADI JAIL ROAD KALYAN WEST ADHARWADI JAIL ROAD KALYAN WEST

Country : India State : Maharashtra Country : India State : Maharashtra

District : Thane Taluka : Kalyan District : Thane Taluka : Kalyan

Pin code : 421301 Pin code : 421301

Since when applicant is residing at Correspondence address (YYYY) : 2004

3 : APPLICANT EDUCATION DETAILS

S Education Name of Duration of Duration of Applicant Caste (As Other Caste Status
r. Educational Education Education Category Mentioned (As (Completed/
N Institute/ School From To In Mentioned In Progress)
o /College Address Educational In
with Telephone No. Certificate) Educational
Certificate)
1 Primary K D M C SCHOOL 2009 2013 Other Agri (169) -- Completed
Education NO 12 UMBARDE Backward
KALYAN Class
2 Secondary GEIS 2013 2019 Other Agri (169) -- Completed
Education SUBHEDARWADA Backward
KALYAN Class
3 College S H JONDHALE 2019 2022 Other Agri (169) -- Completed
Education POLYTECHNIC Backward
DOMBIVALI EAST Class

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4 : APPLICANT'S FAMILY DETAILS
Full Name of Applicant's Father: ARUN RAJARAM KHARUK

Full Name of the Applicant's Grand Father: RAJARAM RAMA KHARUK

Permanent Address of Father (If Father is not alive, then please mention full address of his last Residence) :
UMBARDE GAON NEAR HANUMAN MANDIR. ADHARWADI JAIL ROAD KALYAN WEST

Country : India State : Maharashtra

District : Thane Taluka : Kalyan

Pin code : 421301

Is Applicant's Father Literate?: Yes No

S Education Name of Duration of Duration of Applicant Caste Other Caste Status

r. Educational Education Education Category (Completed/
N Institute/ School From To In Progress)
o /College Address
with Telephone No.
1 Secondary ABHINAV VIDYA 1983 1987 Other Agri (169) -- Completed
Education MANDIR KALYAN Backward
Class

Applicant's Father Occupation: Contact Number: Inherited Profession of Family:

FARMER 8652140392 FARMER

Office/ Business address with contact No:

KALYAN

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5 : FAMILY MIGRATION DETAILS
State Migration

Is Applicant/Applicant's Family migrated to Maharashtra State? Yes No

From Which State? : Migration Year? :

Reason For Migration? :

Native Place Migration

Is Applicant/ Applicant's Family left the native place? Yes No

Who Left the place? : When left Native place (YYYY)?

Reason For Leaving : :

Whether Applicant/ Applicant's family holding house/land at native place? Yes No

Name of the relative who is residing at native Place currently: ARUN RAJARAM KHARUK

Relation with Applicant: Father

Address Of the Relative staying at Native Place:

UMBARDEGAON TAL KALYAN

Contact No. of Relative: 8652140392 Email Address of Relative :

6 : FAMILY CASTE VALIDITY CERTIFICATE DETAILS

Whether the Caste Validity Certificate Scrutiny of any member of the family has done earlier?: Yes No

Name of Relative:

Relation with Applicant:

Scrutiny Committee:

Purpose Of Scrutiny NILL

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When Verification took place? : Caste Validity Certificate No. of relative:

Date of issue of Caste Validity Certificate:

If Rejected give it's details: No

If applicant has applied for caste validity certificate before any committee in state of Maharashtra: Yes No

Name of Committee:

Category: Caste:
Date of Application: Committee Decision: Valid
Invalid
Pending

7 : UPLOAD DOCUMENTS
WOULD YOU LIKE TO TAKE BENEFIT UNDER BLOOD RELATION FROM PATERNAL SIDE, IF ANY? Yes No

(A) Important Primary Document (Mandatory)-Upload Scan copy of Original Certificate/ Document.

(a-1) Caste Certificate of Applicant

(a-2) FORM-17 - Affidavit to be produced alongwith Caste Scrutiny application Form

(a-3) Original Affidavit (In Specimen Form-3, [Rule - 4(1)] Affidavit of Claimant / Parent(s))

(a-4) Form-15A - Certificate to be given by Principal of the School/College

(a-5) Applicant Photo

(a-6) Applicant Signature

(a-7) Applicant's Parent Signature

(B) Important Secondary Documentary Evidence Proof Prior to deem Date only to Prove Caste Claim (Atleast one of

the document can be upload)-Upload Scan copy of Original Certificate/ Document or upload Attested copy in case of Xerox.

(b-1) Certified Copy of Birth Certificate of Applicant's or Applicant's Father/Real Elder Uncle/Real Aunt/Grand Father (From Paternal side) issued by Competent Authority Prior to deem Date

(b-2) Certified Copy of Applicant's Primary School Leaving Certificate/School Register's Extract

(b-3) Certified Copy of Applicant's Father Primary School Leaving Certificate/School Register's Extract

(b-4) Certified Copy of School Leaving Certificate/School Register's Extract of Grand Father/Real Elder Uncle'/
Real Aunt (From Paternal Side)

(b-5) If relatives from Paternal side are illiterate, then Birth/Death Extracts of Father/Real Elder Uncle'/ Real Aunt/Grand
Father (From Paternal Side) issued by Competent Authority (Village Extract No.14/Kotwar Book/Nationality Register)

(b-5) Any Other documents supporting Caste claim (Applicant can upload multiple VC under Blood Relation type.)

(b-6) Attested Xerox copy of identity card issued by the college

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(b-7) If any of the above documents are not available, then attach other relevant documents (mention)

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(b-8) Entry of caste mentioned in the documents of blood relatives from paternal side, registered before deemed
date of respective caste category, e.g. sale or purchase deed of land, house or other immovable property,
mortgage deed, agreement, inam sanad through which rights have been transferred

(b-9) Entry of caste of blood relatives from paternal side in National Registration Book mainly from Aurangabad Revenue Division.

(b-10) Documents related to Inam land available in the records of Directorate of Archives revealing the evidence of caste

(b-11) Entry of caste in the extract of Village Mutation Register, documents in the Format of `Ka`, `da`, `ee`, patra, entries
of caste of blood relatives from paternal side mentioned in the documents of old Court proceedings

(b-12) Government and semi-Government certificates containing traditional Occupation of caste in the old Caste System in respect
of ancestors in blood relations from paternal side, entered before deemed date.

(b-13) Old record wherein name of traditional occupation is mentioned as caste In lieu of surname.

(b-14) Sanad or Proceedings before deemed date, in which the tenant has been declared as the landlord, as per the provisions
of the Maharashtra Tenancy and Agricultural Lands Act (LXVII of 1948) or any other law, revealing the entry of caste.

(b-15) Entries of caste in Census record entered before deemed date.

I am producing certified copy of above documents with my application. I declare on oath that the information furnished
by me in this application is true and correct. I am aware that incomplete application will be rejected and responsibility
of making fresh application will be of mine.

Place: Thane Applicant Signature

Date: 23-08-2022

Applicant's Father/Guardian
Signature/Left Thumb Impression

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