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(See paragraph 27(1)(a)) Appendix 5(A)
APPLICATION FORM FOR MUTATION
Applicant Details(Please fill n the block letters)
Name
Name of father/Husband/Representative:
Present address:
caste Pinz
Mobile no. T
Email ID i
"Permanent Address:
ii)Schedule of property.
Rice:
District: Tohas
Police station: village: ‘Thana no:
Khatano. | Plotno. | Kissam | Totalarea | Trasancted area | Nameofrecordedtenant [Name of
vendortin
case of sale
purchase) Name and Address of tenant as per ROR
Village L
cast a i
| | ea
“ye of mutation: sale purchase/inheritence/Parttion Court decree/Any other (please spec
Documents related( All documents between recorded tenent and present purchaser)
Name of Document T Document No./year | Name of vendor Name of Vendee Name of SR/OSR
(it applicable) (if applicable) office
|
Ee
[coseno fear Tame ofthe court Date of
Wwe.
there by declare that the
3/0,0/0,W/0.
information provided by me in the application is true to the best of my knowledge and belief.
Place: * Signature of the applicant/Authorised representative
Date: ECLARATION
“| Shri/Miss/MRS. Son off
Daughter of/Wife of. age. of
(detailed address)
PS. District. Odisha, do hereby declare that
information given by me in this application form and its self-attested enclosures is true to
the best of my knowledge and that the information furnished is exhaustive and | have
not suppressed any fact. That, | am solely responsible for the accuracy of the declaration
and information furnished and liable for action under section 199 and 200 of the Indian
Penal Code in case of wrong declaration and informaticn. Also, 1am well aware of the
all the benefits
the fact that the certificate shall be summarily cancelled ani
fact
availed by me summarily withdrawn in case of wrong declaration and information.”
Place :
Date Signature / Thumb Impression
Of the applicant. =,"
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