From,

______________________________
______________________________

To,
The Tahasildar & Taluka Executive Magistrate,
Belgaum.

Sub:- ISSUE OF THE DOMICILE CERTIFICATE REG.

Sir,

I, the undersigned _________________________________________________

resident of _______________________________________________________________
request for your kind consideration and necessary action.

Sir, I am permanent resident of ‘KARNATAKA STATE’ residing at

‘BELGAUM’ since the last _________________/BY BIRTH hence native of
KARNATAKA STATE.

I am educated at __________________________________________________
and my father is educated at _____________________________________________
he is doing _________________________________________ at __________________

This certificate is required for _____________________________________

purpose only.

Early action is requested.

Thanking you.
Yours Faithfully,

Place: Belgaum.
Date: (______________________________)
Sign of the Applicant

* R.C. Office / N.I.C. Office, Belgaum

 DOMICILE QUESTIONNAIRE

QUESTIONS ANSWERS

1 What is your full name and :

address
2 a) When and where were you
born?
b) Where were you educated?
c) Have you ever been to your :
former native place? If so, for how
many times and for how long on
each occasion? When did you last
visit it? If not, what prevented you
from going there?
d) Are you married? If so, has your
wife ever been to your native place
and if yes often and how long on
each occasion?
e) How many children, have you?
Where were they or are they being
educated and what are they
doing?
f)For how many years have you
and your family been residing in
State of Karnataka.
g) Have you are your wife any
property in your former native
place or elsewhere out side the
State of Karnataka? If so, where
and of what description and
value?
h) Have you or wife or either of
you ever had any immovable
property in the State of
Karnataka? If so, of what
description and value.
3 a) When and where was your
father born?
b) What was or is his profession or
occupation?
c) Where was his home or place of
permanent residence at the time of
your birth?
d) Where was he when you
attained majority?
e) If he alive? If not, when and
where did he die?
4 Was your father ever in the State
of Karnataka if he was -
a) Where was he educated?
b) In ehat capacity did he come to
the State of Karnataka or work
there?
c) How often if at all, did he leave
or has he left the State of
Karnataka and for how many on
each occasion?
d) If your father is alive, where is
he and what is he doing. Has he

* R.C. Office / N.I.C. Office, Belgaum

 retired, if so, how long did he
remain in the State of Karnataka
after retirement?
e) If your father is dead, had he
retired before his death, if so, how
long did he remain in the State of
Karnataka after retirement.
f) Has or had your father or
mother any immovable property in
the State of Karnataka or else
where? If so, where and of what
description and value?
5 Have or had you any brother or
sisters, if so, how many? Where
were they being educated? Where
are they now and what are they
now and what are they doing? If
any of them are dead, where did
thay died and what were their
occupations?
6 Have you ever claimed been
deemed to be a native of any place
other than a place in the State of
Karnataka for the purpose of your
appointment to any office or for
confirment upon you of any
scholarship, or other privileges in
that place.
7 a) For what purpose is the
Certificate of Domicile Required?
b) What is your religion?
c) Are you a member of a
Scheduled Caste or a Scheduled
Tribe or a community classified as
a backward by the State Govt.
(Answer Yes or No)
d) If the answer to (b) above is yes,
give particulars.
e) Did you apply for a certificate of
Domicile at any time before and if
so, when?

Place:
Date:
Signature of Applicant

N.B. : If it is found that the replies given by the applicant to the questions,
set above, or to any of them are incorrect any admission obtained or
benefit derived thereby shall be summarily concelled.

* R.C. Office / N.I.C. Office, Belgaum

 CERTIFICATE OF AGE, NATIONALITY, DOMICILE ETC.,
(Issued by Authorities in the State of Karnataka)
On Submission of the Proof noted below.

IT IS HEREBY CERTIFIED THAT

Shri/Smt.
_______________________________________________________________

was borh on the _____________________________ day of

______________________in the year One thousand Nine Hundred and
__________________________ at _____________________ in the STATE OF
KARNATAKA, within the territory of India:
that he/she is a CITIZEN OF INDIA
that he/she is domiciled in the State of Karnataka (add if necessary)
by reasons of ;
that he/she belongs to a community declared to a Schedule Caste/
Scheduled Tribe/Backward Community.

PARTICULARS OF PROOF SUBMITTED :

a) Answers given by the applicant on the prescribed form of
Questionnaire.
b) Birth/Baptism/Matriculation or School leaving or a like Certificate
issed by ;
c) Affidavit or declaration of
d) (Other proof)

Dated at ___________________ this __________________ day of ________________

No.

Belgaum Taluka Executive Magistrate, Belgaum.

Dated:

* R.C. Office / N.I.C. Office, Belgaum