EXTRAORDINARY

PUBLISHED BY AUTHORITY

No.1958 CUTTACK, WEDNESDAY, OCTOBER 16, 2019 /ASWINA 24, 1941

[No. 31204– RDM-GOEB-MISC-0039/2015/R&DM.]

REVENUE & DISASTER MANAGEMENT DEPARTMENT

RESOLUTION

The 15th October, 2019

In supersession of the Odisha Miscellaneous Certificates Rules, 2017 and

subsequent amendments issued from time to time and circulars issued thereunder, the

State Government do hereby make the following rules, namely:-

1. Short title, extent and commencement - (1) These rules may be called the Odisha

Miscellaneous Certificates Rules, 2019.

(2) They shall come into force from the date of publication in the Odisha Gazette.

(3) The certificates under these Rules shall be issued only to the citizens of India.

2. Definitions - In these rules, unless the context otherwise requires-

(1) "Certificate" means a miscellaneous certificate specified in rule 3;

(2) “Income” means income from all sources i.e. salary, agriculture, business,

profession etc.; and

(3) "Revenue Officer" means the Chief Officer in charge of revenue administration

the

District,

Sub-Division

Tahasil. Collector

includes

Additional

District

Magistrate, Sub-Collector includes Additional Sub-Collector and Tahasildar includes

Additional Tahasildar.

3. Categories of miscellaneous certificates and authorities competent to issue -

Subject to the provisions hereinafter contained, a Revenue Officer shall be competent to

grant following categories of miscellaneous certificates, namely:-

Resident Certificate

(Form No. I)

Tahasildar

ii.

Legal heir Certificate

(Form No. II)

Tahasildar

iii.

Income Certificate

(Form No. III)

Tahasildar

iv.

Income and Asset Certificate

(for direct recruitment in civil posts

and services and admission in

educational institutions under

Government of India)

(Form No. IV)

Tahasildar

Income and Asset Certificate

(for admission to specified

educational institutions under

Government of Odisha)

(Form No. V)

Tahasildar

vi.

Solvency Certificate

(Form No. VI)

Tahasildar

(upto Rs.10 lakh)

Sub-Collector

(more than Rs.10 lakh)

vii.

Guardianship Certificate

(Form No. VII)

Collector

4. Application for miscellaneous certificates - (1) A person desirous of obtaining a

certificate shall file before a Revenue Officer an application for issue of -

Resident Certificate, in Form No. 1;

ii.

Legal Heir Certificate, in Form No. 2;

iii.

Income Certificate, in Form No. 3;

iv.

Income and Asset Certificate, in Form No. 4;

(for direct recruitment in civil posts and

services and admission in educational

institutions under Government of India),

Income and Asset Certificate, in Form No. 5;

(for admission to specified educational

Institutions under Government of Odisha)

vi.

Solvency Certificate, in Form No. 6; and

vii.

Guardianship Certificate, in Form No.7

by affixing court fee stamp of denomination of three rupees or such amount as may be

notified by the Government, from time to time:

Provided that where application is filed electronically, the application fee may also

be realized through any electronic mode:

Provided further that the Government may also exempt the application fee for some

or all such certificates under such conditions as may be specified.

(2) In case of a minor or person incapable of managing his/her own affairs, the family

members / guardian can file application before the Revenue Officer for issue of

certificates.

(3) The applicant shall submit the documents as mentioned in the Application Form

prescribed for issue of each certificate.

5. Criteria for issue of miscellaneous certificates -

(1) Resident certificate for a locality in the State shall be issued to a person, who

has been residing continuously for a period of at least one year within the jurisdiction of the

concerned Tahasil; however, the same may be relaxed for government employees who

have been transferred and women who have been married within the past one year.

(2) Legal heir certificate shall be granted for –

drawal of pension, gratuity, arrear salaries, provident fund;

ii.

receipt of government assistance, ex-gratia payment;

iii.

withdrawal of money from financial institutions and post offices:

iv.

registration of document relating to transfer of land and buildings;

change of name in case of utility services/basic amenities like electricity

connection, water connection, LPG connection etc:

Provided that in disputed cases the applicants may be advised to approach the

competent Civil Court for issue of Succession Certificate.

Provided further that the Succession Certificates, which are governed under the

provisions of the Indian Succession Act, 1925 shall not be granted by the Revenue

Officers.

(3) While granting Income certificate, income of all members of the family living in a

common mess from all sources i.e. income from salary, wage, remuneration in whatever

form received from Government service/ P.S.U. or Private; income from the movable

properties; income from trade or business or profession; income from agriculture

etc. during the financial year prior to the year of application shall be taken into account.

(4) Income and Asset Certificate for direct recruitment in civil posts and services

and admission in educational institutions under Government of India shall be issued

basing on the following guidelines.

a. Persons who are not covered under the scheme of reservation for SCs, STs

and OBCs and whose family has gross annual income below Rs. 8.00 lakh

(Rupees eight lakh only) are to be identified as Economically Weaker

Sections (EWSs) for benefit of reservation;

b. “Income” shall include income from all sources i.e. salary, agriculture,

business, profession etc. for the financial year prior to the year of application;

c. Persons whose family owns or possesses any of the following assets shall be

excluded from being identified as EWS irrespective of family income;

Ac. 5.00 dec. of agricultural land and above;

II.

Residential flat of 1000 sq. ft. and above;

III.

Residential plot of 100 sq. yards or 900 sq. ft. and above in NACs,

Municipalities and Municipal Corporations; and

IV.

Residential plot of 200 sq. yards or 1800 sq. ft. and above in the areas

other than the urban areas mentioned above at (III).

d. The property held by a ‘Family’ in different locations or different places / cities

would be clubbed while applying the land or property holding test to

determine EWS status;

e. The term ‘Family’ for the purpose will include the person who seeks benefit or

reservation, his/her parents and siblings below the age of 18 years and also

his/her spouse and children below the age of 18 years;

(5) Income and Asset Certificate for admission to specified Educational Institutions

under Government of Odisha, shall be issued to the Economically Weaker Sections

(EWSs) candidates who do not belong to the SCs, the STs and the SEBCs (State list)

categories and whose family has gross annual income below Rs. 8.00 lakh (Rupees eight

lakh only). All other criteria mentioned at clause 4 (b) to (e) shall be followed for issue of

such certificate.

(6) While issuing Solvency certificate, immovable properties situated within the state

of Odisha only shall be taken into account. For this purpose, the Revenue Officer shall

obtain the market value of the land from the Sub-Registrar and valuation of building from

the Executive Engineer / Assistant Executive Engineer / Assistant Engineer and any

Department of Government.

(7) The Guardianship certificate shall be granted by the Collector for limited

purposes such as receipt of pension, family pension, retirement/death gratuity and

government assistance etc. to the legal guardian of the minor or person incapable of

managing his/her own affairs.

6. Institution of the case and issue of certificate - (1) The Revenue Officer shall

institute a case, verify the relevant records / documents and self declaration furnished by

the applicant. Wherever necessary, he may call for a report of inquiry by a specified date

from an officer subordinate in rank or may himself inquire into the matter.

(2) Before issue of Legal heir certificate, the Revenue Officer shall issue a

proclamation in Form VIII inviting objections from the public regarding list of the legal heirs

of the deceased within fifteen days of the proclamation. The proclamation should be

signed by at least five persons of the locality.

(3) If on the basis of the documents, records, and the result of an inquiry the

Revenue Officer is of the view that the certificate applied for may be granted, he shall pass

necessary orders in the case record and sign the appropriate certificate.

(4) The certificate shall be handed over to the applicant or his duly authorized

agent on due acknowledgement of receipt.

(5) When the application is filed electronically, the certificate shall also be issued

through electronic mode with digital signature of the Revenue Officer.

(6) If the Revenue Officer is of the view that the certificate applied for may not be

granted, he shall pass necessary orders in the case record, briefly recording the reasons

thereof.

(7) The time limit for disposal of applications for issue of Miscellaneous

Certificates shall be as follows:

Resident certificate … fifteen days

ii.

Income certificate … fifteen days

iii.

Income and Asset Certificate … fifteen days

iv.

Legal heir certificate … thirty days

Solvency certificate … thirty days

vi.

Guardianship certificate … thirty days

(8) The Revenue Officer may at his discretion issue Resident and Income

certificates on the basis of declaration of the applicant and supporting documents

furnished by him without resorting to any further inquiry.

Provided that if any person gives false information and declaration, he shall be

liable for punishment under section 199, 200 and 420 of Indian Penal Code and other

relevant laws/ rules. In that event, the certificate shall be cancelled and the benefits

accrued thereof shall be withdrawn.

Provided further that the Revenue Officer who has issued the Resident and Income

certificate based on self declaration of the applicant, shall cause an inquiry by himself or

through an officer subordinate in rank to him in some cases chosen at random to ascertain

whether the applicant has furnished correct declaration or not. Upon such inquiry, if it is

found that the applicant has furnished wrong declaration, he shall forthwith cancel the

certificate and pass orders for revocation of the benefits that might have been accrued

thereof after giving the person concerned a reasonable opportunity of being heard. He

shall also proceed to initiate criminal action against the applicant.

7. Rectification of clerical errors. - Notwithstanding anything contained in these rules, if

it is revealed on subsequent verification or otherwise that the contents of the certificate

require modification on account of clerical errors which are apparent on the face of record,

the Revenue Officer shall be competent to rectify the errors and issue the corrected

certificate.

8. Cancellation of certificate. - If any certificate is granted wrongly for any reason other

than wrong declaration by the applicant as mentioned under Rule 6(8), the Revenue

Officer shall bring it to the notice of his next higher authority, who shall then proceed to

cancel the certificate and pass orders for revocation of the benefits that might have been

acquired by the applicant.

Provided that no order shall be passed without giving the person concerned a

reasonable opportunity of being heard.

9. Withdrawal of benefit.- Any person securing an appointment in any office or in an

establishment or securing admission in an educational institution on the basis of a

certificate issued basing upon false information / declaration shall be liable for termination

from service / removal from the institution.

Provided that no order shall be passed without giving the person concerned a

reasonable opportunity of being heard.

10. Appeal.- Any person aggrieved by an order passed by the Revenue Officer under rule

6 may prefer an appeal before -

a) the Sub-Collector concerned, if the order was passed by a Revenue Officer, below

the rank of the Sub-Collector;

b) the Collector concerned, if the order was passed by the Sub-Collector; and

c) the Revenue Divisional Commissioner concerned, if the order was passed by the

Collector.

Provided that no appeal under these rules shall be entertained unless it is preferred

within a period of thirty days from the date of the said order.

11. Revision.- The Revenue Divisional Commissioner (RDC), when certificate has been

issued by Collector; and the Collector, when the certificate has been issued by any

Revenue Officer subordinate to him, may call for the records on his own motion or on an

application and set aside the said orders on merit.

Provided that no order shall be passed without giving the person concerned a

reasonable opportunity of being heard.

12. Interpretation.- If any question arises relating to interpretation of these rules, it shall

be referred to Government in Revenue and Disaster Management Department for

clarification / decision.

Form No. 1

[See Rule 4 (1)]

APPLICATION FORM FOR ISSUE OF RESIDENT CERTIFICATE

1. Personal Details:

Name of Applicant

___________________________________________

Gender

_________________

Marital Status

_________

Age

_________________

Mother’s Name

___________________________________________________

Father’s Name

___________________________________________________

*Husband’s Name

(In case of married women)

___________________________________________________

Mobile No.

___________________

Aadhaar No.

_______________

e-Mail ID

___________________________________________________

2. Permanent Address:

*Village/ Town: __________

Police Station: _________

Post Office: ____________

Tahasil: _________________

District: _______________ Pin: __________________

State: __________________

3. Present Address:

*Village/ Town: __________

Police Station: ________

Post Office: _____________

Tahasil: _______________

District: ______________

Pin: ___________________

State: __________________

4. *Family members/Guardian details (in case of minor & person who is unable to manage

his/her own affairs):

Name: _______________________________________________________

Relation with applicant: __________________________________________

5. Purpose: __________________________________________________

Paste

Applicant’s

Photo

(Passport size)

6. Copy of documents attached:

i) Any one of following documents

Copy of RoR / Electricity Bill / Landline Telephone Bill / Water connection bill / Holding

tax receipt/ Lease agreement with house owner / Certificate from the employer/ First

page of Bank Passbook / extract of latest Voter list / EPIC / Aadhaar Card / Ration

Card / NREGS Job card / other (please specify)

Declaration:

I do hereby declare that the information given by me in this application form is true

to the best of my knowledge and I have not suppressed / misrepresented any fact. That, I

am solely responsible for the accuracy of the information furnished and shall be liable for

action under section 199, 200 and 420 of Indian Penal Code and other relevant laws/ rules

in case of furnishing wrong information. Also, I am well aware of the fact that the certificate

shall be summarily cancelled and all the benefits availed by me shall be summarily

withdrawn in case of furnishing wrong information.

Place:

Date:

Signature of the Applicant / Family member/ Guardian

*Strike out which is not applicable

Form No. 2

[See Rule 4 (1)]

APPLICATION FORM FOR ISSUE OF LEGAL HEIR CERTIFICATE

1. Personal Details

Name of Applicant

_______________________________________________

Gender

_______________

Marital Status

_____________

Age

_______________

Father’s Name

__________________________________________________

*Husband’s Name

(In case of married women)

__________________________________________________

Mobile No.

_______________

Aadhaar No. ___________________

e-Mail ID

___________________________________________________

2. Permanent Address:

*Village/ Town: __________

Police Station: ________

Post Office: ____________

Tahasil: ________________

District: _____________

Pin: ___________________

State: _________________

3. Present Address:

*Village/ Town: __________

Police Station: ________

Post Office: _____________

Tahasil: ________________

District: ______________

Pin: ___________________

State: __________________

4. *Family members/Guardian details (in case of minor & person unable to manage

his/her own affairs):

Name: _____________________________________

Relation with Applicant: ___________________________________

5. Purpose: _________________________________________

Paste

Applicant’s

Photo

(Passport size)

6. Details of deceased person:

Name of the Deceased person: ________________________________________

Age:__________

(on the date of death)

Gender:________

Place of Death:_______

Date of death: _____

7. Legal heir details:

Sl.

No.

Name

Age

Marital Status

Relationship with

deceased

8. Copy of documents to be attached

i) EPIC / Aadhaar Card

ii) Copy of death certificate

iii) Copy of the first page of Service Book if deceased was a Government employee

Declaration:

I do hereby declare that the information given by me in this application form is true

to the best of my knowledge and I have not suppressed / misrepresented any fact. That, I

am solely responsible for the accuracy of the information furnished and shall be liable for

action under section 199, 200 and 420 of Indian Penal Code and other relevant laws/ rules

in case of furnishing wrong information. Also, I am well aware of the fact that the certificate

shall be summarily cancelled and all the benefits availed by me shall be summarily

withdrawn in case of furnishing wrong information.

Place:

Date:

Signature of the Applicant / Family member/ Guardian

*Strike out which is not applicable

Form No. 3

[See Rule 4 (1)]

APPLICATION FORM FOR ISSUE OF INCOME CERTIFICATE

1. Personal Details

Name of Applicant

______________________________________________

Gender

_______________

Marital Status

__________

Age

_______________

Father’s Name

_______________________________________________

*Husband’s Name

(In case of married women)

_______________________________________________

Mobile No.

_______________

Aadhaar No. ___________________

e-Mail ID

__________________________________________________

2. Permanent Address:

*Village/ Town: __________

Police Station: ________

Post Office: ______________

Tahasil: ________________

District: ______________

Pin: ____________________

State: _________________

3. Present Address:

*Village/ Town: ___________

Police Station: ________

Post Office: _____________

Tahasil: ________________

District: _____________

Pin: __________________

State: _________________

4. *Family members/Guardian details (in case of minor & person unable to manage

his/her own affairs):

Name:_______________________________________________________

Relation with Applicant: __________________________________________

5. Purpose: ____________________________________________________

Paste

Applicant’s

Photo

(Passport size)

6. Gross annual income of the family (during preceding financial year )

Sl.

No.

Source

Income (in Rs)

Agriculture

(including

plantation,

horticulture, dairying, poultry, fisheries

etc.)

Salary/ Wages/ Remuneration etc.

Trade/ Business / Profession (please

specify)

Other sources (please specify)

Total

7. Total Income (in Rs) ___________________________________

8. Documents attached

i) Copy of RoR

ii) Salary certificate, if any

iii) IT Returns, if any

iv) Documents in support of other incomes (please specify)

Declaration:

I do hereby declare that the information given by me in this application form is true

to the best of my knowledge and I have not suppressed any fact. That, I am solely

responsible for the accuracy of the declaration and information furnished and liable for

action under section 199, 200 and 420 of Indian Penal Code and other relevant laws/ rules

in case of wrong declaration and information. Also, I am well aware of the fact that the

certificate shall be summarily cancelled and all the benefits availed by me shall be

summarily withdrawn in case of wrong declaration and information.

Place:

Date:

Signature of the Applicant / Family member/ Guardian

*Strike out which is not applicable

Form No. 4

[See Rule 4 (1)]

APPLICATION FORM FOR ISSUE OF INCOME AND ASSET CERTIFICATE

(for direct recruitment in civil posts and services and admission in educational institutions

under Government of India)

1. Personal Details

Name of Applicant

_________________________________________

Gender

_____________

Marital Status

______

Age

_____________

Mother’s Name

___________________________________________________

Father’s Name

___________________________________________________

*Husband’s Name

(In case of married women)

___________________________________________________

Mobile No.

___________________

Aadhaar No.

_________________

e-Mail ID

___________________________________________________

2. Family Details

Mother’s Name

__________________________________________________

Father’s Name

__________________________________________________

*Spouse Name

__________________________________________________

*Sibling Details

(below the age of 18 years)

_________________________________________________

*Children Details

(below the age of 18 years)

__________________________________________________

3. Permanent Address:

*Village/ Town: __________

Police Station: ________

Post Office: _______________

Tahasil: ________________

District: ______________

Pin: _____________________

State: _________________

4. Present Address:

*Village/ Town: __________

Police Station: ________

Post Office: _____________

Tahasil: ________________

District: ______________

Pin: ___________________

State: __________________

Paste

Applicant’s

Photo

(Passport size)

5. *Family members/Guardian details (in case of minor & person unable to manage

his/her own affairs):

Name: _____________________________________

Relation with Applicant: __________________________________________

6. Annual income details of the preceding financial year of family income:

Sl.

No.

Source

Income (in Rs.)

Salary

Business

Agriculture (including plantation, horticulture,

dairying, poultry, fisheries etc.)

Profession

Other sources (Please specify)

Total

7. Asset Details

Sl.

No.

Asset

Area

(in Ac./Sq.

yd./ sq.ft)

Location

Agricultural land

Residential Flat

Residential Plot in the urban area

Municipal Corporation / Municipality / NAC)

Residential Plot in areas other than the urban

area stated above (rural area)

Total

N.B: 1 sq.yd = 9 sq.ft

8. List of Documents attached:

i) Copy of RoR

ii) EPIC / Aadhaar card

iii) Copy of salary certificate, if any

iv) IT returns of last financial year, if any

Declaration:

I do hereby declare that the information given by me in this application form is true

to the best of my knowledge and I have not suppressed / misrepresented any fact. That, I

am solely responsible for the accuracy of the information furnished and shall be liable for

action under section 199, 200 and 420 of Indian Penal Code and other relevant laws/ rules

in case of furnishing wrong information. Also, I am well aware of the fact that the certificate

shall be summarily cancelled and all the benefits availed by me shall be summarily

withdrawn in case of furnishing wrong information.

Place:

Date:

Signature of the Applicant / Family member/ Guardian

*Strike out which is not applicable

Form No. 5

[See Rule 4 (1)]

APPLICATION FORM FOR ISSUE OF INCOME AND ASSET CERTIFICATE

(for admission to specified Educational Institutions under Government of Odisha)

1. Personal Details

Name of Applicant

_________________________________________

Gender

_________________

Marital Status

______

Age

_________________

Mother’s Name

___________________________________________

Father’s Name

___________________________________________

*Husband’s Name

(In case of married women)

____________________________________________

Mobile No.

___________________

Aadhaar No.

_________________

e-Mail ID

_____________________________________________________

2. Family Details

Mother’s Name

__________________________________________________

Father’s Name

__________________________________________________

*Spouse Name

__________________________________________________

*Sibling Details

(below the age of 18

years)

_________________________________________________

*Children Details

(below the age of 18

years)

__________________________________________________

3. Permanent Address:

*Village/ Town: __________

Police Station: ________

Post Office: _______________

Tahasil: ________________

District: ______________

Pin: _____________________

State: _________________

Paste

Applicant’s

Photo

(Passport size)

4. Present Address:

*Village/ Town: __________

Police Station: ________

Post Office: _____________

Tahasil: ________________

District: ______________

Pin: ___________________

State: __________________

5. *Family members/Guardian details (in case of minor & person unable to manage

his/her own affairs):

Name: ______________________________________________________

Relation with Applicant: __________________________________________

6. Annual income details of the preceding financial year of family income:

Sl.

No.

Source

Income (in Rs.)

Salary

Business

Agriculture (including plantation, horticulture,

dairying, poultry, fisheries etc.)

Profession

Other sources (Please specify)

Total

7. Asset Details

Sl.

No.

Asset

Area

(in Ac./Sq.

yd./ sq.ft)

Location

Agricultural land

Residential Flat

Residential Plot in the urban area

Municipal Corporation/ Municipality / NAC)

Residential Plot in areas other than the urban

area stated above (rural area)

Total

N.B: 1 sq.yd = 9 sq.ft

8. List of Documents attached:

i) Copy of RoR

ii) EPIC / Aadhaar card

iii) Copy of salary certificate, if any

iv) IT returns of last financial year, if any

Declaration:

I do hereby declare that the information given by me in this application form is true

to the best of my knowledge and I have not suppressed / misrepresented any fact. That, I

am solely responsible for the accuracy of the information furnished and shall be liable for

action under section 199, 200 and 420 of Indian Penal Code and other relevant laws/ rules

in case of furnishing wrong information. Also, I am well aware of the fact that the certificate

shall be summarily cancelled and all the benefits availed by me shall be summarily

withdrawn in case of furnishing wrong information.

Place:

Date:

Signature of the Applicant / Family member/ Guardian

*Strike out which is not applicable

Form No. 6

[See Rule 4 (1)]

APPLICATION FORM FOR ISSUE OF SOLVENCY CERTIFICATE

1. Personal Details

Name of Applicant

_____________________________________________

Gender

_________________

Marital Status

__________

Age

_________________

Mother’s Name

______________________________________________

Father’s Name

______________________________________________

*Husband’s Name

(In case of married women)

______________________________________________

Mobile No.

________________

Aadhaar No.

______________

e-Mail ID

___________________________________________________

2. Permanent Address

*Village/ Town: ___________

Police Station: _________

Post Office: _____________

Tahasil: _________________

District: _______________ Pin: ___________________

State: __________________

3. Present Address

*Village/ Town: ___________

Police Station: _________

Post Office: _____________

Tahasil: _________________

District: _______________ Pin: ___________________

State: __________________

4. *Family member/Guardian details (in case of minor & person unable to manage his/her

own affairs):

Submitter's Name: ______________________________________________

(in case the submitter is not the applicant)

Relation With Applicant:__________________________________________

5. Purpose: _________________________________________

Paste

Applicant’s

Photo

(Passport size)

6. List of Immovable Properties Approximate value (in Rs.)

(i) Land

(ii) Buildings

(iii) Any other immovable properties (to be specified)

__________________________________________________________________

Total

7. Solvency Certificate applied for amount (in Rs.): _________________

8. List of Documents attached:

i) EPIC / Aadhaar Card

ii) Copy of RoR

iii) List of immovable properties

iv) Encumbrance Certificate for each immovable property

v) Valuation of the land/building, if any

Declaration:

I do hereby declare that the information given by me in this application form is true

to the best of my knowledge and I have not suppressed / misrepresented any fact. That, I

am solely responsible for the accuracy of the information furnished and shall be liable for

action under section 199, 200 and 420 of Indian Penal Code and other relevant laws/ rules

in case of furnishing wrong information. Also, I am well aware of the fact that the certificate

shall be summarily cancelled and all the benefits availed by me shall be summarily

withdrawn in case of furnishing wrong information.

Place:

Date:

Signature of the Applicant / Family member/ Guardian

*Strike out which is not applicable

Form No. 7

[See Rule 4 (1)]

APPLICATION FORM FOR ISSUE OF GUARDIANSHIP CERTIFICATE

1. Personal Details

Name of Applicant

_____________________________________________

Gender

______________

Marital Status

__________

Age

______________

Mother’s Name

______________________________________________

Father’s Name

______________________________________________

*Husband’s Name

(In case of married women)

______________________________________________

Mobile No.

________________

Aadhaar No.

______________

e-Mail ID

___________________________________________________

2. Permanent Address

*Village/ Town: __________

Police Station: ________

Post Office: ____________

Tahasil: ________________

District: ______________

Pin: ___________________

State: _________________

3. Present Address

*Village/ Town: __________

Police Station: ________

Post Office: ____________

Tahasil: ________________

District: ______________

Pin: ___________________

State: _________________

4. *Family members/Guardian details (in case of minor & person unable to manage

his/her own affairs):

Submitter's Name (in case the submitter is not the applicant) :_____________________

Relation With Applicant:__________________________________________

5. Purpose: _________________________________________

Paste

Applicant’s

Photo

(Passport size)

6. Legal Guardian:

Name: _________________________________

Age: __________________

Father’s Name: _________________________________

*Village/ Town: ___________

Police Station: _____________

Tahasil: ___________

District: ________________

Relation with the minor/person unable to manage his/her own affairs ____________

7. List of Documents

i) Birth certificate (If minor)

ii) Certificate in support of disability (if applicable)

iii) Legal heir certificate

iv) EPIC / Aadhaar card

v) Documentary

evidence

support

receipt

pension/family

pension/

retirement/death gratuity etc. of the deceased

Declaration:

I do hereby declare that the information given by me in this application form is true

to the best of my knowledge and I have not suppressed / misrepresented any fact. That, I

am solely responsible for the accuracy of the information furnished and shall be liable for

action under section 199, 200 and 420 of Indian Penal Code and other relevant laws/ rules

in case of furnishing wrong information. Also, I am well aware of the fact that the certificate

shall be summarily cancelled and all the benefits availed by me shall be summarily

withdrawn in case of furnishing wrong information.

Place:

Date:

Signature of the Applicant / Family member/ Guardian

*Strike out which is not applicable

FORM No. I

(See Rule 3)

GOVERNMENT OF ODISHA

Office of the Tahasildar ………………………………..

Miscellaneous Certificate Case No..……………………of 20………

RESIDENT CERTIFICATE

This is to certify that *Shri/Smt./Miss ………………….…………….. son/ daughter of

………………………….…………..(Mother), and Shri …………………………(Father), *W/o

_________________________________ (in case of married woman) is a native /

permanent resident of the district of …………………….. in the state of *Odisha / in the

state of …………………… (mention the name of the State in case s/he originally belongs

to other State) and *she/he or *her/his family is presently residing at *Village/Town

………….…………………………

P.S……………………………..………..

Tahasil………………… in the district of ……………………. in the state of Odisha

for _________ year(s) & ______ month(s) .

Signature of the Revenue Officer

Date ….……………………..

Designation (with seal of office)

*Strike out which is not applicable

FORM No. II

(See Rule 3)

GOVERNMENT OF ODISHA

Office of the Tahasildar ………………………………..

Miscellaneous Certificate Case No..……………………of 20………

LEGAL HEIR CERTIFICATE

This is to certify that the person/persons specified below is/are the legal heir/heirs of

late *Shri/Smt./Miss ……………………………….…………….. *son/ daughter/wife of Shri

………………………….of

*Village/Town…………………………

P.S……………………………..………..

Tahasil…………………

the

district

……………………. in the state of Odisha.

2. This certificate is being granted only for the purpose specified in the Odisha

Miscellaneous Certificates Rules, 2019 ( purpose to be specified).

Name of the Legal heir(s)

Age

Marital

status

Relationship with

the deceased

Signature of the Revenue Officer

Date ………………………..

Designation (with seal of office)

*Strike out which is not applicable

FORM No. III

(See Rule 3)

GOVERNMENT OF ODISHA

Office of the Tahasildar ………………………………..

Miscellaneous Certificate Case No..……………………of 20………

INCOME CERTIFICATE

(Valid for the Financial Year …………………. )

This is to certify that *Shri/Smt./Miss ……………………………….…………….. *son/

daughter

………………………….…………..

(Mother)

and

Shri

…………………………(Father), *W/o ………………………….………….. (in case of married

women) is a native / permanent resident of the district of …………………….. in the state of

*Odisha / in the state of …………………… (mention the name of the State in case he

originally belongs to other State) and *she/he or *her/his family is presently residing at

*Village/Town………….……………………P.S……………………..………..

Tahasil………………… in the district of ……………………. in the state of Odisha has an

annual

family

income

Rs.

……………………..(Rupees

……………………………….…………. ) only from the sources specified below.

Sl.

No.

Source

Income (in Rs)

Agriculture

(including

plantation,

horticulture, dairying, poultry, fisheries etc.)

*Salary/ Wages/ Remuneration etc.

*Trade/ Business / Profession (please

specify)

Other sources (please specify)

Total

Signature of the Revenue Officer

Date ………………………..

Designation (with seal of office)

*Strike out which is not applicable

FORM No. IV

(See Rule 3)

GOVERNMENT OF ODISHA

Office of the Collector………………………………..

Miscellaneous Certificate Case No..……………………of 20………

VALID FOR THE YEAR ____________

INCOME AND ASSET CERTIFICATE TO BE PRODUCED BY

ECONOMICALLY WEAKER SECTIONS

This is to certify that Shri/Smt./Kumari ………………………………………..

son/daughter/wife

………………………………………

permanent

resident

…………………………………… Village / Street ………………………………… Post

Office……………………………District ……………………….., in the State of Odisha, Pin

Code ………………………. whose photograph is attested below belongs to Economically

Weaker Sections, since the gross annual income* of his/her “family”** is below Rs.8.00

lakh (Rupees Eight Lakh only) for the financial year__________. His/her family does not

own or possess any of the following assets***:

5 acres of agricultural land and above;

II.

Residential flat of 1000 sq. ft. and above;

III.

Residential plot of 100 sq. yards and above in notified municipalities;

IV.

Residential plot of 200 sq. yards and above in areas other than the notified

municipalities;

2. Shri/Smt./ Kumari ……………………………….…………….. belongs to the caste which

is not recognized as a Scheduled Caste, Scheduled Tribe and Other Backward Class

(Central List).

Signature of the Revenue Officer

Date …………………

Designation (with seal of office)

Recent

passport size

attested

photograph of

the applicant

*Note 1: Income covered all sources i.e. salary, agriculture, business, profession,

etc.

**Note 2: The term “Family” for this purpose include the person, who seeks benefit of

reservation, his/her parents and siblings below the age of 18 years as also his/her

spouse and children below the age of 18 years.

***Note 3: The property held by a “Family” in different locations or different

places/cities have been clubbed while applying the land or property holding test to

determine EWS status.

FORM No. V

(See Rule 3)

GOVERNMENT OF ODISHA

Office of the Collector………………………………..

Miscellaneous Certificate Case No..……………………of 20………

VALID FOR THE YEAR ____________

INCOME AND ASSET CERTIFICATE TO BE PRODUCED BY

ECONOMICALLY WEAKER SECTIONS

This

certify

that

Shri/Smt./Kumari

………………………………………..

son/daughter/wife

………………………………………

permanent

resident

…………………………………… Village / Street ………………………………… Post

Office……………………………District ……………………….., in the State of Odisha, Pin

Code ………………………. whose photograph is attested below belongs to Economically

Weaker Sections, since the gross annual income* of his/her “family”** is below Rs.8.00

lakh (Rupees Eight Lakh only) for the financial year__________. His/her family does not

own or possess any of the following assets***:

5 acres of agricultural land and above;

II.

Residential flat of 1000 sq. ft. and above;

III.

Residential plot of 100 sq. yards and above in notified municipalities;

IV.

Residential plot of 200 sq. yards and above in areas other than the notified

municipalities;

2. Shri/Smt./ Kumari ……………………………….…………….. belongs to the caste which

is not recognised as a Scheduled Caste, Scheduled Tribe and Socially & Educationally

Backward Class (State List).

3. The certificate is being issued for the purpose of admission to specified educational

institutions in the state of Odisha, notified by Government of Odisha from time to

time.

Signature of the Revenue Officer

Date …………………

Designation (with seal of office)

Recent

passport size

attested

photograph of

the applicant

*Note 1: Income covered all sources i.e. salary, agriculture, business, profession,

etc.

**Note 2: The term “Family” for this purpose include the person, who seeks benefit of

reservation, his/her parents and siblings below the age of 18 years as also his/her

spouse and children below the age of 18 years.

***Note 3: The property held by a “Family” in different locations or different

places/cities have been clubbed while applying the land or property holding test to

determine EWS status.

FORM No. VI

(See Rule 3)

GOVERNMENT OF ODISHA

Office of the Tahasildar / Sub-Collector……………………………..

Miscellaneous Certificate Case No..……………………of 20………

SOLVENCY CERTIFICATE

This is to certify that *Shri/Smt./Miss ………………….…………….. *son/ daughter

…………………………………………….…………..(Mother),

Shri

………………………………… (Father), *W/o Shri …………………………. (in case of

married

women)

*Village/Town………….………………P.S………………………..

Tahasil………………… in the district of ……………………. in the state of Odisha is

solvent to the extent of Rs………………. (Rupees ……………………………..…….) only.

Immovable Properties Approximate value (in Rs.)

(i) Land

(ii) Buildings

(iii) Other immovable properties (to be specified)

____________________________________________________________________

Total

Signature of the Revenue Officer

Date………….………………

Designation (with seal of office)

*Strike out which is not applicable

FORM No. VII

(See Rule 3)

GOVERNMENT OF ODISHA

Office of the Collector………………………………..

Miscellaneous Certificate Case No..……………………of 20………

GUARDIANSHIP CERTIFICATE

This is to certify that *Sri/Smt./Miss ………………………………………………. *son/

daughter

wife

.......................................................…………………………..of

*Village/Town………………………..P.S.

………………….………………….……Tahasil

…………………..in the district of …………………… in the state of Odisha is the legal

guardian

*Sri/Smt./Miss………………………………………

aged

………

years,

*son/daughter/wife

…………………………………………….…..………

*Village/Town…………………………..P.S…………………Tahasil……………………in

the

district………………………….. in the state of Odisha who is a *minor/ person incapable of

managing his/her own affairs.

2. This certificate is being granted only for the purpose of ………………………

Signature of the Revenue Officer

Date………….………………

Designation (with seal of office)

*Strike out which is not applicable

FORM No. VIII

[See Rule 6(3)]

GOVERNMENT OF ODISHA

Office of the Tahasildar ………………………………..

Miscellaneous Certificate Case No..……………………of 20………

PROCLAMATION

It is hereby informed to the general public that *Shri/Smt./Miss………………

………………………………….. *son/daughter/wife of ………………………………………. Of

*Village/Town……….……………………………

P.S……………..………..

Tahasil………………… in the district of ……………………. in the state of Odisha has

applied

for

issue

legal

heir

certificate

Late

…………………………………….*son/daughter/wife

…………………………………….

who died on ……………….

As enquired by the RI………………….., the following persons are found to be legal

heir (s) of Late…………………………………………………………………………..

Name of the Legal heir(s)

Age

Marital

status

Relationship with

the deceased

. Anybody having any objection to the list of legal heirs may file objection within a

period of fifteen days from the date of this publication.

No objection shall be entertained after expiry of the schedule period.

Signature of the Revenue Officer

Date ..........................

Designation (with seal of office)

*Strike out which is not applicable

ORDER

Ordered that this Resolution be published in an Extraordinary issue of the

Odisha Gazette and copies should supplied to all Departments / all Heads of Departments/

all R.D.Cs / all Collectors / all Sub-Collectors / all Tahasildars.

By Order of the Governor

NIKUNJA BIHARI DHAL

Principal Secretary to Government

Printed and published by the Director, Printing, Stationery and Publication, Odisha, Cuttack-10

Ex. Gaz. 1289-173+600