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, -._wvrr|l" oF KERAl,qReverue (p) Departmenr

NOTIFIC4TION

Rurrs

2012

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1

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"APPeut

[See Rule 1 i (8) and.16 (1)l

Application Form forAssignment o{ Land on Regtsiry

I. Narne ofaPPlicant

2. Nalionaliry olthc aPplicant

f . ,lg" 'nO

Date of Birth

4. Name of Wife 'Husband , :

5 Present address

r Dcrmanent address{As given rn

" ni'i* curo eiection'Card'

Passpofl or UID Card)

': 1:Tfi'j:[:::ff# lJilJi.,

(a) Ration Card numbe

@) Election Card nrimb

(c) UtD Card number

(d) Passport numb€r

8. Phone numbe":'il1i"ll11*,-,re aPolicarrt al the ttme u

' (a) Mohile Phone

ft) Land Pbone

o Whether the aPplicant belongs to

' *,:Hil;^;) rIY""'nu'"th'

category

!n \ hetber thc aPPiicant is an

'u l--tt}t"^"" (Yes\'lo) I{Yes'

give details

: the applicant is disabledactive military service ora

ofthose who killedactive military sen ice). Ifyes, give details

the appJicant belongs toholders' with annual incdmer than. ( 25,000

). If yes, give details

the applicant is a recipientaward from Military

of such a person). If yes, give dehils

and annual familyof the applicant

of assignment

site/cultivationrbenefi cial

of Iand in possession/

of land owned or occupiedr applicani and/or his fanrilvcm (iointly o.r severdliyJ

.#

I E{ent (Aq€r'Cent/Sq, Merre)

4

PART I

lDetails of total land in Possgsslon

Dand in Pqssession' situated in-

(a) Mllage

O) Tahi(

' G) Distriot

6) SurveyNunbet

"*lJll,"Ilt::", centsi sq m etre)

3. Boundaries ofland in possessiort-

(a) . South

'O) Nonh

(c)'East

(d) West

4. Nature ofland (wet or dr,)

Teriure of land (Re*'.* TT::'

i

JJ,]*"'*",n*o"Putotobf

5erlarr .{f

,n and enjoYment of the rs a Iandlesq person or u O"r*gd9, o""upying any landjsDistrist to rvhich priority is

for assignrnent

Districts to which priority is

Fir.st

Second

Third'

Fourth

Fiftl

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