Annexure-III FORM NO. - 25 ( SeeRule12-A (1) (a)) Application of a rayat for conversion of agricultural land for non-agricultural purpose To The Authorised Officer, 1. Name of the rayat : 2. Father's/ Husband's Name : 3. Address : 4. Specific purpose for which the land will be utilized after conversion : 5. Particulars of land (a) Holding Number : (b) Plot Number : (c) Area : (d) Classification and status as per current R.O.R. : (e) Village with Thana Number : (f) Other, if any : 6. Whether land is situated in any area within one-half Km. on either side of a National Highway/ one fourth Km. Km. on either side of State Highways, if so, the details thereof. : 7. Whether the land situated in Municipal/ N.A.C./ Developing area, if so the details thereof. : 8. Date from which the land is intended to be used/ already used for non-agricultural purpose. : 9. Source of ownership : 10. Approximate market value of the land : Signature of the Applicant Date IN THE COURT OF ______________________________ PETITION FOR PERMISSION ( ANNUMATI ) 1. Name of the petitioner with address including : Caste/Tribe 2. Total extent of land held by the petitioner : 3. Extent of land with Khata No, Plot No and : village proposed to be sold 4. Name of the recorded tenant of the land proposed : for sale 5. Proposed price of the land : 6. Reasons for the sale of the land : 7. Name of the purchaser with address including : Caste/Tribe DECLARATION I Sri/Smt. __________________________________________________________ son/wife of __________________________________________ village ________________________ P.O. ______________________ P.S. _____________________ District ________________ do hereby declare that the contents of the petition are true to the best of my knowledge and belief. Place : Signature of the Applicant Date :
