Affix one recent
Court Fee Stamp as required passport size
photograph
APPLICATION FORM FOR CERTIFY COPY
(Fields marked * are mandatory)
Service Payment Details :
1.Service Charges of the Kiosk Operator per unit = 20.00
2.Printing Charges per unit = 5.00
3.Scanning Charges per unit = 5.00
4.DeGS Charges per unit = 2.00
_____
Total 32.00
_____
(the above amount may vary based on no of printing and scaning page counts)
(charges are applicable based on the service to which the Certified Copy is applied )
Documents Required
Mandatory Documents Supporting Documents
No Supporting Documents
1.Land Record.*
Delivery Time Lines
Estimated Timelines To Process The Application (Expected Date of Delivery) : 4 days
(Expected date is calculated including Holidays)
Personal Details
Applicant Name* :- ___________________ ___________________ ___________________
Gender* :- ___________________ Marital Status* :- ___________________
Date of Birth* :- ___________________ Age*
Parents Details
Father Name* :- ___________________ ___________________ ___________________
Mother Name* :- ___________________ ___________________ ___________________
Spouse Details
Spouse Name* :- ___________________ ___________________ ___________________
Relation With
:- ___________________
Applicant*
Contact Details
Phone No :- ___________________ Mobile No :- __________________
Email :- ___________________
Permanent Address
House No/Name* :- ___________________ Village * :- __________________
District * :- ___________________ Sub Division * :- __________________
Tahsil * :- ___________________ RI * :- __________________
Block * :- ___________________ Police Station * :- __________________
Post Office * :- ___________________ Pin * :- __________________
Application Specific Details
Caste/Tribe * :- ___________________ Sub Caste/Sub Tribe * :- ___________________
:- ___________________ :- ___________________
Copy of which
___________________ Available At section* ___________________
document*
___________________ ___________________
:- ___________________
Available at Office* ___________________
___________________
:- ___________________
Service * :- ___________________ Purpose* ___________________
___________________
Land Record Details
Is ROR Produced? Yes No
(If "YES" please provide the Land record Details)
District* :- ___________________ Sub Division * :- __________________
Tahsil * :- ___________________ RI * :- __________________
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
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 * :- __________________
Block * :- ___________________ Police Station * :- __________________
Post Office * :- ___________________ Pin * :- __________________
Supporting Documents
1. Land Record. *
Applicant Signature :- ___________________
