FORM FOR CERTIFICATE OF IDENTIFICATION To be submitted in Triplicate with three passport size photograph of Applicant Passport size Passport size photograph of photograph of the the applicant guardian 1.0 PERSONAL DETAILS OF THE APPLICANT A. Name: B. Sex and Marital Status: C. Fathers / Husbands Name: D. Date of Birth and Age: E. Address: i. Block: ii. Panchayat Unit: iii. Name of the Panchayat Ward Member: iv. Town (if Urban): F. Details of Family members (Required only the details of wife and children) Sl.No. Name Relationship Sex & Age 2.0 DOES THE APPLICANT POSSESS SIKKIM SUBJECT CERTIFICATE? (Yes / No), If yes (A) Serial No (B) Volume No (C) Block Please attach a copy of the Sikkim Subject Certificate, duly attested. 3.0 DOES THE FATHER/ HUSBAND AND PATERNAL GRAND FATHER / BROTHER FROM THE SAME FATHER OF THE APPLICANT POSSESS A SIKKIM SUBJECT CERTIFICATE? (YES / NO) If yes please furnish the following details; (a). Relationship with the owner of the SSC (b). Serial No (c). Volume No & Block Name of SSC holder (please attach a copy of the Sikkim Subject certificate, duly attested.) 4.0 DOES THE APPLICANT OF HIS HER FATHER/HUSBAND POSSESS LANDED PROPERTY IN THE RURAL AREA EITHER IN THE OLD LAND RECORDS OF 1952-54 OR, THE NEW ONES OF 1977-79? (YES/NO) If yes; please furnish the following details; (a) In whose name is landed property recorded? Sl. No. Plot No/Area Block / District Relationship with applicant 1952 / 79 5.0 WAS THE APPLICANT HIMSELF/HERSELF, OF, HIS/HER FATHER/HUSBAND EMPLOYED IN REGULAR GOVERNMENT SERVICE ON OR BEFORE 31ST OF DECEMBER 1969? If yes; please furnish the following details; (A) Name of the person having proof of Service with order no. and issue date. (B) Relationship with the applicant (this could be the applicant himself/herself) (C) Department; Date of joining (Please attach a copy of the proof of service duty attested) (This section needs to be filled up only by women applicants) 6.0 IS THE APPLICANT MARRIED? (YES/NO) If Yes, Please furnish the following details; (A) Is the application being made on the basis of the husband's documents? (Yes/No) If No. Please furnish the following details; (B) Does the applicant's father possess a Sikkim Subject Certificate? (Yes/No) If Yes, Please give details thereof. (C) Does the applicants father/paternal grandfather/brother from the same father possess a Sikkim Subject Certificate? (Yes / No) If Yes please give details thereof. 7.0 IS THE APPLICANT ORDINARILY RESIDENT IN THE STATE OF SIKKIM? (YES / NO) 8.0 DOES THE APPLICANT POSSESS ANY OF THE FOLLOWING ADDITIONAL DOCUMENTS? (Latest One) (A) Electoral Identity Card / Election Certificate (Yes / No) If yes, give details (B) Birth Certificate (Yes / No) If yes, give details (C) School leaving / joining certificate (Yes / No) (D) Any other documents ? ( Yes / No ) If yes, give details (E) Two passport size photograph enclosed (Please attach attested copies of all documents as above, along with the application form) I Solemnly affirm that the statement made in the foregoing paragraphs ( para 1.0 to 8.0 ) are true to the best of my knowledge. 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. Hence, on the basis of the above facts, and the undertaking, I may kindly be granted a certificate of Identification Signature & Name of the Guardian Signature & Name of the Applicant ( if alive on the basis of whom the claim is being preferred) FOR EXCLUSIVE OFFICE USE ONLY 1. Comments of the Confidential Section : (a). S.S.C has been verified from our record and found to be correct/not found to be correct (b). Reports from S.P. (SB) and S.P. received and found to be satisfactory (c). Panchayat recommendation received Signature of the Confidential Assistant 2. Land record has been verified as per following Details Signature of Head Surveyor 3. Order : District Collector This form to be filled in a separate page FOR PANCHAYAT VERIFICATION PURPOSES ( TO BE DELIVERED IN SEALED COVER TO THE CONFIDENTIAL SECTION OF THE DISTRICT COLLECTORATE, ) 1.0 The facts, stated by Sri / Smt / Km S/O, D/O, W/O in support of his/her application for a certificate of identification have been scrutinised by us. These facts have been carefully verified and are to be as under. 2.0 (a) Age (b) Whether applicant is a Sikkim Subject holder or name of his /her father, husband, paternal grandfather, brother from the same father are found recorded in the Old Sikkim Subject Register. ( Yes / No ) (c) Whether the applicant has/had agricultural land or in his father / husband / paternal grand - father's name in the rural areas ( Yes / No ) If answer is yes plot number etc may be mentioned 3.0 We agree to bear all penalties, as provided for under the law, if any of the particulars verified by us true / false turn out otherwise 4.0 Accordingly, it is recommended that a certificate of Identification may kindly be issued to the person whose particulars are stated above Signature & Name of the Ward member with seal 1. Signature & Name of the Panchayat Sabhapati 2. Signature & Name of the Panchayat Up -Sabhapati Photograph of the Applicant 3. Signature & Name of the Panchayat Sachiva Official Seal of the Panchayat
