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Annexure-III

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FORM NO. – 25 ( SeeRule12-A (1) (a))

Application of a raiyat for conversion of agricultural land for non-agricultural purpose

To

            The Authorised Officer,

 

1.

Name of the raiyat

:

2.

Father’s/ Husband’s Name

:

3.

Address

 

:

4.

Specific purpose for which the land will be utilized after conversion

:

5.

Particulars of land

 

(a)     Holding Number

:

(b)     Plot Number

:

(c)      Area

:

(d)  Classification and status as per current R.O.R.

:

(e)      Village with Thana Number

:

(f)      Other, if any

:

6.

Whether land is situated in any area within one-half Km. on either side of a National Highway/ one fourth Km. Km. on either side of State Highways, if so, the details thereof.

:

7.

Whether the land situated in Municipal/ N.A.C./ Developing area, if so the details thereof.

:

8.

Date from which the land is intended to be used/ already used for non-agricultural purpose.

:

9.

Source of ownership

:

10.

Approximate market value of the land

:

 

 

 

                                                                                                                              Signature of the Applicant

                                        Date

 

 ------------------------------------------------------------------------------------------------------

 

 

IN THE COURT OF ______________________________ KEONJHAR

 PETITION FOR PERMISSION ( ANNUMATI )

 

1.          Name of the petitioner with address including    :

            Caste/Tribe     

2.          Total extent of land held by the petitioner                        :

3.          Extent of land with Khata No, Plot No and                   :

            village proposed to be sold

4.          Name of the recorded tenant of the land proposed        :

            for sale

5.          Proposed price of the land                                             :

6.          Reasons for the sale of the land                          :

7.          Name of the purchaser with address including    :

            Caste/Tribe

 

 

DECLARATION

I Sri/Smt. __________________________________________________________ son/wife of __________________________________________ village ________________________ P.O. ______________________ P.S. _____________________ District ________________ do hereby declare that the contents of the petition are true to the best of my knowledge and belief.

 

Place    :                                                                                                            Signature of the Applicant

Date      :    

 

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