GOMs No 58

Affix Photo of
the Applicant
along with his
/her Spouse

Format
Appendix-I
Application. No:

APPLICATION FOR ASSIGNMENT OF UNOBJECTIONABLE GOVERNMENT LAND AND SURPLUS

LAND UNDER URBAN LAND CEILING TO AN EXTENT UP TO 125 SQUARE YARDS TO POOR
FAMILIES AT FREE OF COST UNDER G.O.MS.NO. 58, REVENUE (ASSN.II) DEPT., DT.30.12.2014.

1.
2.
3.
4.

Name of the occupant and his /her Spouse

Fathers / Husbands/Wifes Name and other family
members Names
Present Residential Address
Details of the Unobjectionable Government land /Ceiling
Surplus land occupied by way of encroachment:

a). Survey No., Village / Ward No.

b). Extent of land occupied
c). Date from which occupied
(Proof to be produced)
d) Proof of Identity
i. Aadhar Card,
ii. Any other document (such as voter ID
card, Driving License, Passport , Bank
Pass Book)

e). Nature of occupation:Proof of possession

i. Registered Document
ii. Property Tax Receipt
iii. Electricity Bill Receipt
iv. Water bill receipt
v. Any other proof to establish
possession (Building Construction
permission from Local Body)

:
:

(f). Area covered by Structure in Sq.Yards.

(
(Note: See operational guidelines for the said G.O.)
Particulars of Notices, if any received by the occupant
from the Competent Authorities
Details of Court Litigations if any?
Checklist Enclosed Y/N

5.
6.
7.

:
:

DECLARATION
I. S/o. D/o. H/o. W/o of Sri / Smt.
................................................................... declare that the information furnished above is correct. I
agree to the terms and conditions of the G.O.MS.NO. 58, Revenue (ASSN.II) Dept., dt.30.12.2014.
Place:
Date:

SIGNATURE:
Name in Block Letters:
--------------------------------------------------------------------------------------------------------------------

Application.No:
ACKNOWLEDGEMENT FOR APPLICATION UNDER G.O.MS.NO.58 DATED: 30.12.2014.
The application of Sri / Smt . S/o. D/o. / H/o.
W/o. of Sri / Smt ................................................................... is received on _________along with
Check List and enclosures.
DATE:

SIGNATURE WITH SEAL

GOMs No 58

Check List for G.O.Ms.No.58 (Please Mark

1. Application form with Signature
and photo of the applicant & his/
her spouse:
2. Proof of Identity:
1. Aadhar Card

2. Any other document

a. Voter ID card

b. Driving License

c. Passport

d. Bank Pass Book

3. Proof of possession:
a) Registered Document

b) Property Tax Receipt

c) Electricity Bill Receipt

d) Water bill receipt

4. Any other proof to

establish possession
1. Building Construction
Permission from Local
Body

If Yes and x If No)