Panchayat:Repo18/vol1-page1069

b) any dated evidence issued by the Commissioner of Land Revenue or Collector or Revenue Divisional Officer or Tahasildar or Village Officer with respect to the unauthorised reclamation and/or any similar documentary evidence to this effect.

i................

ii................

iii...............

iv..............

c) photographs of the land unauthorisedly filled up, signed by the owner, to the effect that "this is the paddy land which has been filled up unauthorisedly/due to natural reclamation before the 12th day of August 2008"

i................

ii................

iii...............

iv..............

d) Orders obtained earlier, if any, granting permission to utilise the land for any other purpose issued under any law in force before 12th day of August 2008.

<divclass="floatright">Signature of Applicant ........................................ Name of the Applicant ........................................ (In Block letters)

Full address:

Place:

Date:

DECLARATIONBYTHEAPPLICANT

............. hereby declare that the unauthorised reclamation was carried out before the 12th day of August 2008. I also declare that all the information furnished by me are true to the best of my knowledge and belief. I also agree unconditionally that the Collector/Government can take any action as may deem fit if any of the information furnished by me does not confirm to facts.

Signature and name and Address of the Owner

Place:

Date:

DETAILEDREPORT FORM5 (See Rule 5(1)) (to be used by the Collector based on the report of the concerned Village Officer(s) in duplicate Part I

...................................Village

...................................Taluk

.....................................Corporation/Municipality/Grama Panchayat

1. Particulars of application

1. Application received on

2. Name and address of applicant

3. Verified on

4. Returned to applicant for completion

5. Completed application received on

6. Status of land in Draft/Data Bank

7. Sent to Village Officer on

Part II Inspection & Verification Report (to be furnished by the Village Officer, ..........................................)

Date of receipt of Form 5 by the Village Officer...............................................

2. Particulars of land:

1.Sy. Number

2.Re Sy. Number (if any)

3.Extent of paddy land reclaimed

4.Thandapper No:

5.Thandapper holder

6.Nature of land in BTR:

3. Particulars of Current usage of the reclaimed paddy land:

(based on site inspection)

1. Current use of land

Lying fallow/Residential/ Commercial/Commercial-cum-residential/Others (attach site mahassar also)

2. Whether the photograph submitted by the applicant is genuine : Yes/No