Present Address
Is Present Address Same as Permanent Address? Yes No
(If "No" please fill the Present address given below)
House No/Name* :- ___________________ Village *:- _____________________________________________
District * :- ___________________ Sub Division * :- __________________
Tahsil * :- ___________________ RI Circle * :- __________________
Block * :- ___________________ Police Station * :- __________________
Post Office * :- ___________________ Pin * :- __________________
Land Record Details
Is ROR Produced? Yes No
(If "YES" please provide the LandRecord Details)
District* :- ___________________ Sub Division * :- __________________
Tahsil * :- ___________________ RI Circle * :- __________________
Police Station * :- ___________________ Mouza(Revenue Village) * :- __________________
Khata No * :- ___________________ Recorded Tenant (Land Owner) * :- __________________
Relation of the applicant with Recorded
Tenant * :- __________________
Plot Details Sl No. Plot No * Area * Kisam *
1
2
3
4
5
Annual Income Details
Salary / Pension Annual Income * :- __________________ Landed Property Annual Income*:- ___________________
Annual Income(Business)
Sl No. Source * Income *
1
2
3
4
Total Income :- --------------------------------------------------------______________
Children Details
School Going Children * :- __________________ College Going Children* :- ___________________
I, Shri / Smt …………………………………………………..………..Son of / Daughter of / Wife of
……………………………………………………………. resident of village ……………………………………..…. P.S.
…………..…………………… District ……………………..………… and particulars stated above are true to the best of my
knowledge and belief and that they are exhaustive and I have not suppressed any fact. In case it is detected later on that any of the facts
stated herein wrong or that I have suppressed some material facts, I shall be liable for prosecution under the relevant law.
Signature of the applicant.
