Reference No.

Application Date

Application for Non-Creamy Layer

New [ ]

Renewal [ ]

Applicant Details
Aadhaar Number
Full Name *
Gender *

Male

[ ]

Female

[ ]

Date of Birth *
Occupation of
Applicant*
Residence Address *
(Please provide the following
details)

House/Flat No.

Building No. /Building Name

Society/Complex
Road Name
Name of Post Office

Pin Code
Permanent Address *
(Fill if different from above)

House/Flat No.

Building No. /Building Name

Society/Complex
Road Name
Name of Post Office

Pin Code
Mobile No. *
Email
Occupation *
Previous NCL
certificates details (if
applicable) *

Beneficiary Details
Full Name *
Spouse Name *

Certificate Number
Place of Issue
Valid till date

Other

[ ]

Fathers Name *
Mothers Name *
Address where family
originally resides*
Applicants Relation to
Beneficiary *
Religion *
Caste *
Occupation and Income Details of Applicants Family * (Please fill the sections as applicable)
Income from Salary/Pension
Type of Occupation

Father

Mother

Spouse

Central Government

State Government

Private Sector

PSU

Armed forces

Others (Specify)
Occupation Details
Name of Organization

Father

Mother

Spouse

Designation/Rank
Department
Salary Range
Total Annual Income
Date of Joining (dd/mm/yyyy)
If Pensioner, date of
retirement (dd/mm/yyyy)
Income from Business
Type of Business
Total Annual Income
Income from Immovable property
Owner of property

Father

Mother [

Minor

Location
Area (Yards / Sq. Metres / Acres /
Hectares)

Type of agricultural land

Area of irrigated land (Yards /
Sq. Metres / Acres / Hectares)

a) Percentage of irrigated
land as per constitutional
ceiling under the state land
ceiling act formula
b) If you own both irrigated

Irrigated

Dry crop

and dry land, percentage

of irrigated land as per
constitutional ceiling under
the state land ceiling act
formula
As per a) total irrigated land as
a percentage as calculated by
the land ceiling act formula
Cultivation details
Type of cultivation

Crop

Fruits

Location
Cultivated Area (Yards / Sq.
Metres / Acres / Hectares)

Details of land/building in urban area

Location of property
Details of property
Current use of property
Total Annual Family Income
from all sources excluding
salary and agricultural income
Are you an income tax payee
(Attach assessment if yes)

Yes

Have you paid wealth tax

Yes
(Attach details)
(Fields marked with * are mandatory)

No

No

Self-Declaration
I ______________________________________________son/daughter of ________________
_________________________ aged

________ occupation ________________________

hereby declare that the information provided above is true and correct to the best of my
knowledge, information and belief. I fully understand the consequence of giving false
information. If the information as given above is found to be false, I shall be liable to
prosecution and punishment under section 199 and 200 of IPC 1960 and/or any other law
applicable thereto.

Place :

_________________ Applicant Signature

: ____________________________

Date :

___ / ___ / ________ Applicant Name

: ____________________________

List of documents to be attached

(mark [] in case necessary annexure are attached else mark [X])
Mandatory Documents
1.

Identity Proof- Voter ID Card/ Passport/Drivers License/RSBY Card/Aadhaar Card/

Identity card issued by Govt. or Semi Govt. organisations/PAN Card/ MNREGA Job
Card

2.

Address proof- Voter ID Card/ Passport/Drivers License/ Aadhaar Card/ Electricity

Bill/ Water Bill/ Extracts of 7/12 and 8 A / Rent Receipt/ Telephone Bill/ Ration
Card/Property Tax Receipt

3.

Proof of caste for self School leaving certificate mentioning caste / Bonafide
certificate (mentioning caste) issued by school / self attested Xerox of caste certificate
/ If uneducated birth registration extract / Caste and residence certificate issued by
Sarpanch/Local Police/Corporator

4.

Affidavit for caste

5.

Income proof Income tax return for previous 3 financial years, if applicant is salaried
or self employed or businessman / Income certificate from Tahsildar for 3 years, if
applicant is farmer or labourer / Affidavit mentioning income for last 3 years

Additional Documents to be produced as applicable

1.

Property tax receipt

2.

If proof of fathers caste not available, a relatives caste certificate and genealogical
affidavit with details of relation to relative

3.

If applicant migrated from other state/ district, then caste certificate of applicants
father issued by competent authority in that state/district

4.

If married women,
a. Proof of caste before marriage, as prescribed in point no. 3
b. Proof of marriage- marriage registration certificate and name change
notification in gazette

5.

If applicant is Muslim (either of the following document may be submitted)

a) A Investigation report of Tahsildar if his/her fathers caste certificate is not
available
b) Caste certificate issued by registered Muslim Societies

6.

Proof of caste of a relative- Father/Brother/Sister/Grandfather/Uncle/Aunt or any

other blood relationa. School leaving certificate
b. Birth/death extract
c. If in Government service, extract of first page of service book
d. Document certifying caste issued by department of social justice
The above documents should be produced for a the applicant or applicants relative
who is born on or before the following datesOBC/SBC -13/10/1967