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    Common Application Form For Obtaining Various Services From Taluk / Village Office

    Uploaded by

    Ismail Msw
    This document is a common application form for obtaining various certificates from Taluk or Village offices in Kerala, India. It requests information to identify the applicant and determine eligibility for the requested certificate. The form requests details like name, age, address, family details, income details, property details, and place of birth. It also specifies required documents and a declaration of truth. Instructions explain how to correctly fill the form for efficient processing of requests.

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    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd

    Common Application Form For Obtaining Various Services From Taluk / Village Office

    Uploaded by

    Ismail Msw
    98 views4 pages
    This document is a common application form for obtaining various certificates from Taluk or Village offices in Kerala, India. It requests information to identify the applicant and determine eligibility for the requested certificate. The form requests details like name, age, address, family details, income details, property details, and place of birth. It also specifies required documents and a declaration of truth. Instructions explain how to correctly fill the form for efficient processing of requests.

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    This document is a common application form for obtaining various certificates from Taluk or Village offices in Kerala, India. It requests information to identify the applicant and determine eligibility for the requested certificate. The form requests details like name, age, address, family details, income details, property details, and place of birth. It also specifies required documents and a declaration of truth. Instructions explain how to correctly fill the form for efficient processing of requests.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    98 views4 pages

    Common Application Form For Obtaining Various Services From Taluk / Village Office

    Uploaded by

    Ismail Msw
    This document is a common application form for obtaining various certificates from Taluk or Village offices in Kerala, India. It requests information to identify the applicant and determine eligibility for the requested certificate. The form requests details like name, age, address, family details, income details, property details, and place of birth. It also specifies required documents and a declaration of truth. Instructions explain how to correctly fill the form for efficient processing of requests.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
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    You are on page 1of 4

    Affix Court fee

    Stamp for Rs.5/-

    Form 1A
    (see rule 3)
    COMMON APPLICATION FORM FOR OBTAINING VARIOUS SERVICES FROM TALUK /
    VILLAGE OFFICE
    Nature of Certificate applied for ...................
    Purpose : State

    Outside State

    Defence Purpose

    To be produced before ...............................................

    .............................................
    Language in which the Certificate is required :

    English

    Malayalam

    Part I (General Details)


    1. Name of person for whom certificate is applied for .................................
    2.Gender (M/F) .........................................................................................................
    3a. Age : ............. 3b. Date of Birth

    D D

    Details

    MM Y Y Y Y
    4. Present Address

    5. Permanent Address

    House No:
    House Name
    Street / Place
    Post Office
    PIN code
    Village
    Taluk
    District
    Name of Local Body
    Type of Local Body

    Grama Panchayat

    Municipality

    Corporation

    6. Name of Father: ..6a. Religion of Father:.6b. Caste of Father.


    7. Name of Mother: ... 7a. Religion of Mother:7b. Caste of Mother...
    8. Marital Status :

    Married Unmarried Widow Widower Divorced

    9. Name of Spouse : ..........................................................................................................................................


    10. Name of
    Guardian :...................................................................................................................................................................
    11. No. of years residing at the present address: ..............................
    12. Phone (Res.): Code :.. Number :..................................... 13. Mobile: :.......................................
    14.Email: ...................................................................................................................................................
    15. Ration Card No: ......................................

    16. Driving License No: ...........................

    17. Election ID Card No .... 18. Passport No: ...........................


    19. Unique Identity No (UID), if any: ..................

    Part II A (To be filled for Caste/Community/ Conversion/Inter-Caste Marriage Certificate)


    (Items 20d to 20i to be filled if caste / religion has been converted)

    20a. Religion: ..... 20b. Caste: 20c.Category: Gen/SC/ST/OBC ...........................


    20d. Religion before conversion :..............................................20e. Caste before conversion:.................................
    20f. Name before conversion: ....... 20g. Certificate No (issued by the religious authority): ..........
    20h. Dated 20i. Religious Authority: ........................................................................

    Part II B (To be filled for Income Certificate)


    21. Income Details
    Income

    Salary/Pen

    Income

    Income

    Income

    Rental

    Any

    from Land

    sion

    from

    from

    of NRI

    Income

    other

    Business

    Labour

    Member

    Total

    Income

    Self
    Spouse
    Father
    Mother
    Unmarried
    Family
    Members
    Total
    Grand Total in words :

    Part II C (To be filled for Solvency / Land Valuation / Possession/ Non attachment / Location /Income
    certificates)
    22. Property Details
    Old
    Distr

    Talu

    ict

    Vi

    Surve

    Re-

    lla

    y /sub

    Survey

    ge

    Div.

    Block

    No

    ReSurvey
    /Sub
    Div No

    Thanda
    pper
    No.

    Land

    Ext

    Type

    ent

    (Wet/Dr

    (in

    y)

    Ha)

    *Market

    Value of

    Liability

    property

    Amount

    * Tobe filled for Solvency & Land Valuation certificates only

    Part II D (To be filled for Caste/Identification/Nativity /Residential/Domicile Certificates)


    Enter Place of Birth details as follows :
    State

    District

    Taluk

    Village

    23.Applicant
    24.Father
    25.Mother
    Part II E (To be filled for Identification & One and the same Certificate)
    26. Alias name(s): .............................................................................
    27. Identification Marks: (i) ..................
    (ii) .................

    Part II F (To be filled for inter-caste marriage certificate)


    28a. Date of Marriage: ................... 28b. Spouses Religion: ................... ..
    28c. Spouses caste ............................................................................................................................
    Part II G (To be filled for legal heir/widow(er)/ not remarried certificates)
    29. Name and address of deceased /deserted/divorced : .................................................................................................
    30. Date of demise.............31. Employed as : ......................................
    32. Death Certificate No.... 33. Place of Death: ..............
    (Death certificate may be attached)

    34. No.of years since deserted/divorced/dead .

    35. Details of legal Heirship Claimants


    Sl

    Name of person

    Gender

    Relationship

    Age

    Occupation

    Address

    Part II H (To be filled for dependency / relationship / family membership certificates)


    36. Name and address of person with whom related/dependent: .............................
    ................................
    37. Details of Relatives /dependents / family members of the person mentioned above
    Sl

    Name of person

    Gender

    Relationship

    Age

    Occupation

    38. e-District Registration Number if any : ..............................................................................................................................


    39. Enclosures with the application: ............................................................................................................................................
    ...................................................................................................................................................................................................

    DECLARATION

    I do hereby certify that the particulars mentioned above are complete and true to the best of my knowledge and belief. I also
    agree that any loss to Government due to the Incomplete or Incorrect information provided above may be recovered from my
    movable/ immovable assets. I also agree that the certificate so issued and any benefits accrued in lieu of that stands nullified
    on proved mis-representation.

    Place : .................................................................

    Signature : ............................................................................................

    Date: ...................................................................

    Name of Applicant : .............................................................................


    Relationship with the person for whom certificate is applied for
    : ..............................................................................................................
    (Relationship to be specified if the above declaration is signed by Parent
    / Guardian / Authorized Representative)

    Instructions for filling the Application


    1.Please enter the application particulars correctly and completely.
    2.The personal details will be stored in the citizen database as part of the e-District project.
    3.Filling up of e-District Registration Number is mandatory for all future correspondence.
    4.In order to avail services quickly, please ensure that the information given is correct and complete.
    5.Filling up of Part I (General details ) is mandatory in all applications.
    6.Fill up only Part I (General details) for Life Certificate and Destitute Certificate.
    7.For additional information, please refer Kerala Information Technology (Electronic Delivery of Service) Rules, 2010.

    Village officers verification report

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