[To be signed by an officer deemed competent to issue such certificate by the Govt.]
This is to certify that Sri /Kumari.....………………………...s/o. /d/o. ……………………....................... Sri……………………………............ of………………............................…… village…………………...........…....... District/Division…….…………………............................ belong to………………............... community, which is recognized as scheduled caste/scheduled Tribe/backward class by the Government of Andhra Pradesh, India (under subcaste ……………………) in its notification No ………..............| Date: | Signature |
| Name and Designation with Office seal |