APPLICATION FORM FOR SCHEDULED TRIBE/CASTE CERTIFICATE (To be submitted in Triplicate with three passport size photograph of Applicant) To, The District Collector, Sir, I Shri/Smt/Km__________________________________________________S/O,D/O ___________________________________________( Name of parents) at present residing at_______________________________________________________(name of village and GPU/Town) may kindly be granted a Scheduled Tribe Certificate 1. That I belong to the ________________________Which is a sub caste of _________________Caste which is recognised as Schedule Tribe/ Scheduled Caste as per the Constitution ( Sikkim Schedule Tribe/ Scheduled Caste Order, 1978 ) 2. In case of married women, certificate is claimed by Birth or Marriage 3. That the statement made in the foregoing paragraphs are true to the best of my knowledge and belief. 4. That i further undertake that in the event of the particulars given in the declaration being found false, I shall accept whatever penalties are provided for under the relevant provision of Law. 5. Two Passport size photographs enclosed 6. Birth certificate enclosed Signature & Name of the Applicant Note : 1. Children above the age of 18 years to produce certified copy of Sikkim Subject Certificate, Certificate of Identification of their own instead of father's SSC. 2. In case the applicant does not possess SSC/COI, in their own name, then a police verification report is required. 3. In case of women to produce Birth Certificate/Panchayat report to certify the name of father and caste/tribe of parents. PROCESS SHEET The following attested / Certified documents have been submitted by the applicant (a). Sikkim Subject Certificate/ Certificate of Identification / Citizenship Certificate (b). Birth Certificate/Panchayat report to certify the name of father & Caste/ Tribe (c). School Certificate indicating name of father and exact date of birth of children entered in register on admission to school in support of father's S.S.C (d). Panchayat verification report/ Report from Area MLA 1. Remarks ( if any ) Dealing Assistant 2. Proposed Action Office Superintendent 3. Orders District Collector 4. Follow up action a. Entries in issue register made vide No dated b. Issue no. entered in certificate ( Yes / No ) c. Certificate issued after taking proper receipt ( Yes / No ) Dealing Assistant
