This is to certify that Shri/ Shrimati*/ Kumari*................son / daughter*of...............of village / Town* ................in District / Division *of..........the State / Union Territory*.................belongs to the Caste / Tribe* which is recoginised as a                                                                Scheduled Caste
                                                                  ______________
                                                                  Scheduled Tribe*

under :

*The Constitution (Scheduled Castes) order, 1950.
*The Constitution (Scheduled Tribe) Order 1950.
*The Constitution (Scheduled Castes) (Union Territories) Order,1951
*The Constitution (Scheduled Tribes) (Union Territories) Order,1951

(AS amended by the Scheduled Castes and Scheduled Tribe Lists (Modification Order,1956 the Bombay Reorganisation Act,1960, the Punjab Reorganisation Act, 1966, the State of Himachal Pradesh Act.1970, the North-Eastern Areas (Reorganisation Act, 1971 and the Scheduled Castes and Scheduled Tribes order (Amendment) Act,1976.)

* The Constitution (Jammu and Kashmir) Scheduled Caste Order, 1956.
* The Constitution (Andaman and Nicobar Islands) Scheduled Tribes Order,1959
as amended by the Scheduled Castes and Scheduled Tribes Orders (Amendment)Act,1976.
* The Constitution (Dadra and Nagar Haveli) Scheduled Tribes Order,1962,
* The Constitution (Pondicherry) Scheduled Castes Order,1964,
* The Constitution Scheduled Tribes (Uttar Pradesh) Order 1967,
* The Constitution (Goa, Daman and Diu) Scheduled Castes Order 1968,
* The Constitution (Goa, Daman and Diu) Scheduled Tribes Order,1978;
* The Constitution (Nagaland) Scheduled Tribes Order,1970.

2, Shri/ Shrimati*/ Kumari*......... and/or* his/her* family ordinarily resides(s)in village / town*.........of............Division* of the State / Union Territory* of..........

Signature....................
Designation
(with seal of office)
State

State

Union Territory

Place...................
Date....................

*Please delete the words which are not applicable.