"Co Mal TS A NSA TkaiA_ I 3) rence Fa: 3) am 2) Proyaita ar a) aes Ser ¥) OF Aaa ©) Gaeta APT ee AR, 3) eit afer mia Ca Frame : ) ARE I, WI a, A OPT 2) afer ae cae THe ert | itera |e ‘Soar wrt aR ora | atta cat | * niin erg | eeDECLARATION FORM (To be affirmed before the Notary Public) 1, Sri/Smt... -S/0, D/O, W/O Sri/Smt. residing at under Police Station . in the district of ..... do hereby affirm and declare as follows: |. That I am the absolute owner of the plot of land described in the schedule below by way ot being the legal heir of .......... . from whom it is so inherited on. -++nddue to, a 2. That [ have been possessing the said plot of land since... free from all encumbrances. Uninterruptedly and it is 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 involved in any Court case. 5. That I shall apply for long term settlement of the said plot of land on such terms and conditions and on payment of such salami and rent as the State Government may fix in this regards, if the said plot of land is 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 of land to the State Government. 6. 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. 7. 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. 8. 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 provision of the any law for the time being in force. % The Statements made here in above are true to the best of my information, knowledge and belief and nothing material has been concealed therein. District | Police | Mouza Station | with - J.L. No. Total [ Area | Recorded Area | Owned | Classification Full Signature of the DeclarantAPA Hapa mae GA 6 Pit Tea SIRRCrA UIAPR- 9. cece ceeee sees eeenteeeeeeeeess orate aM vRorst BT aarertt ARG OF FE : >) Ra afer a 2a a 2) Bal wera ah 2a at cae TAR ) « Geattens sen 7a :aL ja AAT THB (aA Renae serie erect gery CPE GRPUR/ AA FRA) 8) ei seria aim >a ja gw Brera art opie caret ts a a vy) Dae UF RG AR aT : or a ANE AE 9) FRR CITA ACIS AIRE wT: ST ar acme AR] (ra ara ACP one aT OC Get oT) URE AK BE TERA, SPICE BAAS FA UA TY, A HSA TAUICET FCF Bocas oars ae (Grae ae 7+) afteia aT shears ay epraist aT fet Fat OFA AL | GOAT NTC ME AAR AR ART HST SHCA FT SAT HOS SLAY Fa AIT orate Aira TRANS Tere wutNOTICE UNDER SECTION 57 READWITH SECTION 50/50A of W.B.L.R Act Mutation Case No.............:cccsssssscesssereessaeeessseaenseneasseeeesnenseee FRTS HA faeore (RL: FOR Wt Vato mrnesists Wace AACS CMTS : BRAG] OAC CAF occ eeeseeeeeeeeeeeee Dit TR CHAT Gates fret ere VSIA fra RE A CIPI Goa one acres Ae ota ae are Woes ef aT WR ARAUISTIT HAT MSIE AL BAA worn Reaset were wR oer : rat mR L.R. =fSaR AR LR. ait Ae ofr fam: 3) prt afrT e oe FS Afra =P cHCw BBA 2) Me wn afer orn user a oneS Baa wo) Seats fea cam Beatie yen CS Zeca 8) Sete BA ARETE aE ora FI SHC CRP = FT aS eT CH 8 ATTN, Cem 38 OATOFFICE OF THE BLOCK LAND & LAND REFORMS OFFICER BARRACKPORE-I, SHYAMNAGAR Memo No .. Date To The Special L.A.O. North 24 Parganas, Barasat Sub: Land Acquisition the following plot/plots for disposal of Mutation/Conversion petition submitted by Sri/Sm. Cast No. The mutation/conversion petition submitted by Sri/Smt. 8/0, D/O, W/O. is under consider of this office, his/her option in the matter of granting Mutation/Conversion is urgent required. The extract of land transferred in this case along with names of vendor(s) and vendee(s) are encumbered below: (Schedule of the Land) 01, Name of Mouza with J.L.No. 02. Name of Police Station 03. R.S. LR. Khatian No 04. R.S. /L.R. Dag No 05. Classification of Land 06. Total Area of the Land 07. Area Transferred 08. Date of Transfer vide deed No 09, Name of the R.S. /L.R. Recorded Tenant 10. Name of the vendor(s) with address 11, Name of the Vendee(s) with address 12, REMARKS He is requested to be the undersigned know if the schedule land is connected to any land acquisition proceedings or is in the process of being acquired in the near future. Sketch map in case of acquired land any alienation map if the land is party acquired should kindly be provided along with your kind comment, with 30 days. Block Land Reforms Officer Barrackpore-I, ShyamnagarGovernment of West Bengal Office of the Block Land Reforms Officer, Barrackpore-1 Dist. -24 Parganas (North) Memo No.. Date...... The Competent Authority and Sub Divisional Officer isposal of Mutation/Conversion Petition Submitted by Sri/Smt. Case No. ‘The Mutation/Conversion petition submitted by Sri/Smt. $/0, DIO. WiO.. . is under consideration of this office. In reference. to the standing circular of the A.D.M and D.L. &R.O. North 24 Parganas, Barasat his opinion in the matter of granting Mutation/Conversion is urgently required. The exact of the land transferred in this case along with the name of the Vendor(s) and Vendee(s) are enumerated below. SCHEDULE OF LAND 1, Name of Mouza with J.L. No. 2. Name of Police Station : 3. R.S. /R.L. Khatian No. 4.R.S. /R.L. Dag No. 5. Total area of Land : 6. (a) Area Transferred (b) Date of transfer vide deed No. : 7. Recorded Classification 8. Name of the R.S. recorded tenant : 9. Name of the vendor(s) with address : 10, Name of the vendor(s) with father/ : Husband's Name and Address 11. Purpose for Mutation/Conversion 12. Remarks : He is repressed to let the undersigned know if the schedule and has been vested of him/her under any section of the ‘UL(C&R) Act, 1976 within 30 days. Two copies of affidavit are enclosed for his office records are 1 copy may be returned back by him with necessary nothing of vesting in case of the schedule land in ultimately vested as per UL(C&R) act 1976. Prescribed Authority ‘USS (50), of WBLR act (1955) & Revenue Officer BLALRO Office Barrackpore-1, Shyamnagar