rena Rant grr aes ge FOR RAL WA PHA) wr oell eee aig are 81 ga hog Ze) ug aE ch ger dian Sw ~ (four Bum). femnae B HER)Registration Form (Filled In block letter In English} | Seneral infornfation: 1. District: a semmiiciantuitsita 2, Sub Division an 3. etehsll: norte, 4, Bloek: 5. Gram jnnchorts si: 6, Villager village Code 1 Qersonal information: 8. Land Owner’s Name (In Hindi ): 9. (In English): (as per Bank Passbook) 10, *Aadhaar No. (copy enclosed) 23, Father's/Husband Namet 12. Gender: Male/Female/Transgender 14, Category: General/@c/Sc/ST 15, Dateof Birth: Jac osesl 16, Movie NOt acai V7. adress:- ii ee 18, Ownership: Single/toint 19, Khewat NO ee 20. Land area owned : K ccna 1 Family Details: spouse Name: ‘gadhaar No, Land OWNEd 22. Children below 48 years i) NEMO. ABMNIEE NG Land OWN ft) Name Aadhaar NO band OWN eee Aadhaar No, Land owned, ii) Name WY) NBM ABNER NO essences KANG OWNED ences 23, Total Cultivable Land in this village of family tometer: 23 (2). Land owned by the farmer/ his farmly in other villages: x. mM Name of the Village. __ Area of Cultivable Land: Khasra No. V- Exclusion Criteria 24. Former and present holders of constitutional posts: Yes/No 25, All serving or Wetired Class-i/il/il officers and employees of Central/State Government PSU/Local Bodies/ Autonomous Institutions und#r Government: - ‘Yes/No 25, Monthly persion more than Rs. 10,000/- per month:- Yes/No 27 Income Tax Payee: Yes/ No 28, Former and Present Minister/State Minister/MP/Ex -MP/MLA /tx-MLA / Mayor/Gx-Mayor/Zila Parishad chalrman/ExZila30, Name of the Bank: 32, Name of Branch : 32, Account Number: 33. Account Type: Single/soint 24, SC Code: _ 38. KCC Number (If Any): Vil Verification: 1. I hereby undertake that the above sald information is true and nothing false has been stated therein. In case « information is found false, | shall be lable to be proceeded against as per the law time being in force. 2. Thereby agree and give my consent foruse of my Aadhaar Number and other information by the Agriculture and Farm Welfare Department, Haryana and the Revenue and Disaster Management Department, Haryana for the purposes of P Kisan Scheme, 3, [hereby undertake that | and my: family do not hold! more than 40 Kanal (2 Hects) land as on 01-02-2029 and abc mentioned land is under cultivation, Place: . Dates (Signature of Applicant) ‘Vil Remarks after Verification by the Tear Verified Yes/No “ In case of any mismatch of 1) Area, mention Reasons, 2). Name, mention Reasons, 3) Any Other Name, designation signature of team members: - ‘Sr.No. | Name ‘Signature T *if the applicant is not enrolled in Aadhaar, Identity proof in shape of Voter I0/ Ration Card/ Driving License be entered 20d photocopy should be attached. However, this will be valid only for 2" instalinent only under this scheme.