2. Mr/Mrs/Ms...........................son/daughter...........................of...................resident of village............. Tehsil................................. District...................... Chhattisgarh is of.....caste/tribe is a Scheduled Caste of State of Chhattisgarh under Article 341 of the Constitution, which is mentioned on the serial number of Third Schedule of Section 19 of the Madhya Pradesh Reorganization Act, 2000.

Investigation Officer
Inquiry Officer/Member
Chairman
District Level
District Level
District Level
Certificates
Certificates
Certificates
Verification Committee
Verification Committee
Verification Committee
District................
District.............
District............
Chhattisgarh
Chhattisgarh
Chhattisgarh
Form-4D(2)
Form-4D(2)
[ See Rule 17(1)]
Serail No. ...........................
Dated ............................
Verification Certificate
Verification Certificate
(For Scheduled Tribes)
(For Scheduled Tribes)
(On light-pink paper)