Reference No.

Application Date

Application for Non-Creamy Layer

New [ ] Renewal [ ]
Applicant Details
Aadhaar Number
Full Name *
Gender * Male [ ] Female [ ] Other [ ]
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 *
Certificate Number
Previous NCL
certificates details (if Place of Issue
applicable) * Valid till date

Beneficiary Details
Full Name *

Spouse Name *
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 Father Mother Spouse
Name of Organization
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 Irrigated [ ] Dry crop [ ]
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
 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
Yes [ ] No [ ]
(Attach assessment if yes)
Have you paid wealth tax
Yes [ ] No [ ]
(Attach details)
(Fields marked with * are mandatory)

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
Identity Proof- Voter ID Card/ Passport/Drivers License/RSBY Card/Aadhaar Card/
1. Identity card issued by Govt. or Semi Govt. organisations/PAN Card/ MNREGA Job [ ]
Card

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

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

Proof of caste for self School leaving certificate mentioning caste / Bonafide
3. 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 [ ]

Income proof Income tax return for previous 3 financial years, if applicant is salaried
5. 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 [ ]

If married women,
4. 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

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

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

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

other blood relation-
a. School leaving certificate
b. Birth/death extract
6. 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 dates-
OBC/SBC -13/10/1967