Please affix required stamps before submission FROM No.II (See Rule 3) Office of the .... Miscellaneous Certificate Case No... of 200... IDENTITY CERTIFICATE This is to certify that Shri/Smt./Miss ........... son/daughter/wife of Shri ........ Is a resident of Village/Town ........ P.S. ...... Tahasil ............ in the District of ................. in the State of Orissa. 2. His present occupation is ......... 3. This certificate being granted only for the purpose of .......... Signature of Revenue Officer Date: Designation (with seal of office) Signature of the applicant
