Land & Land Reforms And Refugee Relief & Rehabilitation Department

DECLARATION FORM

I, Sri/Smt NUR MOHAMMAD ANSARY son of/daughter of Sri/Smt KETAB residing at KESHYA
MOHANDIH KENDA under Police Station Manbazar in the district of PURULIA do hereby afirm and declare
as follows:

1. That I am the absolute owner of the plot of the land described in the Schedule below by way of transfer vide
Registered Deed No. 3773 dated 29/06/1994 /inheritance being the legal heir ..................................................
from whom it is so inherited on............................................ due to .....................................................

2. That I have been possessing the said plot of land since .......................................................... uninterruptedly
and it is free from all encumbrances.

3. That the said plot of land is neither vested nor acquired by the Government and there is no proceeding
initiated in respect of the said plot of land for its vesting or acquisition till date.

4. That the said plot of land is not vested / does not fall under the purview of the Uraban Land ( Ceiling &
Regulation) act, 1976.

5. That the said plot of land is not involved in any Court Case.

6. That I shall apply for long term settlement of the said plot of land on such terms and condition and on
payment of such salami and rent as the State Government may fix in this regard ,if the said plot of land os
found to have already been vested in the State at any point of time. In case of failure to do so , I shall forthwith
make over vacant and peaceable possession of the said plot to the State Government.

7. That I shall make over possession of the said plot of land to the State Government without any claim , if the
said plot of land is found to have already been acquired by the State Government at any point of time.

8. That I shall pay regularly the land revenue in respect of the said plot of land as may be fixed by the State
Government in accordance with the provision of the West Bengal Land Reforms Act , 1955 as amended from
time to time.

9. That I shall abide by all the terms and conditions as may be fixed by the State Government from time to time
for holding the said plot of land as per privision of any law for time being in force.

10. That the mutation granted shall be liable to be cancelled if any information provided with the mutation
application isfound to be not true.
11. That the statements made hereinabove are true to the best of my information , knowledge and belief an
nothing material has been concealed therein.

DESCRIPTION OF THE PLOT OF LAND

District Police Station Mouza with J.L. No. Khatian No. Plot No. Total Area Area owned

PURULIA Manbazar Damda[007] 69 1700 0.1 acre

PURULIA Manbazar Damda[007] 1087 1700 0.05 acre

............................................................
Full Signature of the Declarant

31/10/2021 , 12:8:14 am