Form No 1 Application for benefit under ‘Krishak Bandhu Scheme (Death Benefit), 2019” [see para V (ii) of the notification] To The Assistant Director of Agriculture, Block, District Subject: Prayer for sanction of benefit under Krishak Bandhu Scheme (Death Benefit), 2019. Sir, 1/we, the following signatories beg to inform you that: sonl wife of _ . resident of village + Post Office _ Ge. Block District who was a farmer! recorded Bhagchashi ( share cropper) has expired on at hours. Tam the nominee of the deceased or, 1/ we are the eligible claimant (s) (5) of the deceased [strike out whichever not applicable] ‘Now, I Ave, pray to your kind end for sanction of the benefit in my /our favour at the earliest. My/ our detailed particulars and copies of other documents, as required, are attached herewith ‘Thanking you. Date Yours faithfully, Place Signature of the applicant(s) Enclosures: i) Detailed particulars of the applicant (s) (Annexure- I). ii) —__Attested copy of identity proof (Voter Card/ Driving Licence/ Passport/ Aadhaar Card / PAN Card etc) of the deceased, iii) Attested copy of death certificate of the deceased farmer. iv) _Attested copy of ‘Krishak Bandhw’ card in case of registered deceased farmer or Eligible claimant (3) certificate issued by BDO of concerned block, in original, for non registered farmer (Annexure- III). ¥) __Attested copy of ROR in case of non registered deceased farmer. vi) Self Declaration by the Applicant (s) (Annexure- IL). vii) Legal / Natural guardian declaration in case of minor claimant (s). Page LofaANNEXURE- DETAILED PARTICULARS OF THE CLAIMANT (S) (add sheets if required) Si] Particulars Claimant (3) No. 1 Claimant (5) No.2 | Claimant (s)No3 ‘Name in full (capital letters) ‘Age (on date of application) oy s|=]z Address Village P.O. GP. Block District PIN 4 Relation with the deceased 3 Tdentity proof EPIC No. ‘Adhaar No. (optional) ‘Any other Govt. photo Identity Card (please specify) No. 6 Land Particulars (Own or Bhagchasi) of the deceased Mouza ILNo Kh. No. Plot No. ‘Area of land I/we hereby declare that: 1) LAve have not claimed and will not claim any other death benefit (viz., snake bite, lightning death) from the State Government due to death of the farmer. 2) The statements made above are true to the best of my/ our knowledge and belief and if any information is found to be false my / our claim will be cancelled forthwith. Signature of the claimant (s) with date Page2of 4ANNEXURE-II (Self Declaration) lie son/daughter/wife of = village oe - PO. Block and of Dist do hereby declare that I /we have not claimed and will not claim any other death benefit (viz., snake bite or lightning death etc.) from the State Government due to death of .. Dated Signature of the claimant (s) ANNEXURE- III (Centificate by the Block Development Officer) As per local enquiry report itis certified that the following (s) is / are the eligible members to get, the benefit of the ‘Krishak Bandhu Scheme (Death Benefit), 2019° due to the demise of Late. son/daughter/wife of village | PO. Block Dist... Si [Name] Father's 7 husband's ‘Address [Age (Vis) | Type ofID | UD.no. [% of No. name Benefit [add rows ifrequired] Date Signature of BDO, Development Block [seal] Page 3 of 4