FORM OF COMMUNITY, NATIVITY AND DATE OF BIRTH CERTIFICATE MCH

Serial No.
S.C.
S.T.
B.C.
Certificate No.

District Code 1 6
Mandal Code
Village Code
COMMUNITY, NATIVITY AND DATE OF BIRTH CERTIFICATE
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This is to certify that Sri / Smt.Kum............................................................................S/o.D/o.Sri..........................................................
of village / Town ...............................................Mandal...................................................District Hyderabad of the State of
Andhra Pradesh belongs to Community which is recognised as S.C. /S.T./ B.C. under :
1950,
1950,
1956,
1976,
23-09-1970
The Constitution (Scheduled Castes) Order, 1950.
The Constitution (Scheduled Tribes) Order, 1950.
S.Cs., S.Ts., list (Modification) Order, 1956.
The S.Cs. and S.Ts. (Amendment) Act, 1976.
G.O.Ms.No.1793 Education Dept., dated 23.9.1970 as amended from time to time (B.Cs.)
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2. It is certified that Sri / Smt. / Kum ...............................................................is a native of Village / Town, Khairtabad Mandal,
Hyderabad District of Andhra Pradesh.
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3. It is certified that the place of birth of Sri / Smt. / Kum. ...............................................................................................................is

.........................................................Village/Town, Khairatabad Mandal, Hyderabad District of Andhra Pradesh.
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4. It is certified that the date of birth of Sri / Smt./ Kum..............................................................................................................is
Day Month Year
(in words) ............................................................................................as per the declaration given by his / her father /
mother / guardian and as entered in the School Records where he / she studied.
Signature:

Date:
/Name in Capital Letters:

Designation SEAL