(REGISTRATION FORM)

1. District:
2. Sub-Division:
3. Circle/Tehsil Block:
4. Block:
5. Name of the Municipality/Gram Panchayat/Village:
6. Full Name of the farmer (in Capital) :
7. Date of Birth: / / Day(DD)/ Month (MM)/ Year (YYYY)
8. Gender: (Male/ Female/ Transgender):
9. Marital Status:
10. Father’s/Husband’s Name:
11. Mobile Number:
12. Aadhar No
13. ID Proof submitted:
14. Residential Address (in block letters) :
15. Pin Code:
16. Category (SC / ST / OBC/GENERAL):
17.Details of family members:
Name of the Date of birth Aadhar No Relation to the Any land
Family member applicant holding
in his/her name

18. Details of Collective land holdings :

A) Type of land holding: Community Based / Private (Please specify):
B) Particulars of collective land holdings

Sn Name Of the Name of CS *Patta No. Area ( in *Any

No. Nomaniee the DAG No. Hectare) CoPattadar
Revenue Of Holding ( in
Village or case of joint
share holdings)
indicating
their shares

Total
in case of community based/privately owned land holdings (prevailing in hill districts), the areas of
such land holding/list of eligible beneficiaries/Exclusion criteria shall be certified/verified by the
concerned Village Chief/ Chairman of Village authority by way of declaration for the beneficiary
concerned indicating share out of the total area owned by the community/private and in such cases,
CS Dag No & Nomaniee No. may be dropped and name of joint owners may be indicated in place of
Co-Nomaniee. Such reports shall be authenticated by the SDOs concerned.

19. Bank details of the farmer/applicant

i. Name of the Bank Branch:
ii. Name of Account Holder:
iii. IFSC Code :
iv. Account Number :
20. Exclusion Criteria:-

i) Former and present holders of constitutional posts: Yes/No

ii) All serving or retired Class-I/II/III officers and employees of Central/ State Government
PSU/Local Bodies/ Autonomous Institutions under Government: - Yes/No

iii) Monthly pension more than Rs. 10,000/- per month:- Yes/No

iv) Income Tax Payee: Yes/ No

v) Former and Present Minister/State Minister/MP/Ex -MP/MLA / Ex-MLA / Mayor/Ex-Mayor/Zila

Parishad chairman/Ex-Zila Parishad Chairman: - Yes/No

vi) Doctors/Engineers/Lawyer/Charted Accountant/Architects registered with professional

bodies: - Yes/No

SELF- DECLARATION
I, Shri/Smt/Km........................................................................................................................... s/o, d/o,
w/o, h/o........................................................................................................................................a
resident of....................................................................................................................under
Tehsil:............................. Sub-Division :.........................District:.............................. do hereby declare
that I am a Small/ Marginal farmer having less than 2(two) hectare of total collective land holding(s)
in the name of my family ; and therefore eligible for availing benefits under Scheme.
2. That, all the statements made in the application form are true and complete to the best of my
knowledge and belief and I understand that in the event of any information being found false or
incorrect at any stage or not satisfying the eligibility criteria according to the requirements, my
application is liable to be cancelled. That, I further declare that I do not fall under any of the
exclusion criteria from being a beneficiary to the Scheme.
3. In case of incorrect self declaration made by me, I shall be liable for recovery of the transferred
financial benefit and shall be liable to be punished as per law of the land.
4. ***Further, I also give my consent and agree that the department responsible for implementation of
the KISAN FUTURE BANK in the Union/ State Government can use the beneficiary Aadhar
number and other information provided to verify the eligibility of the undersigned for the
COMPANY.

Date: Signature / Thumb impression of the farmer:

Place: Name:
Address:

FIELD VERIFICATION REPORT

Name of the Verifying Officer/ Official/ Authority:
Date of verification:
Statements verified and found to be: TRUE / FALSE on field verification.
Recommendation: ELIGIBLE/ INELIGIBLE
Remarks (if any):

Date: Signature of the Verifying Authority:

Place: Name:
Designation:
*** Strike off if not applicable

GUIDELINES OF KISAN FUTURE BANK

1. New Scheme for all small and marginal landholding fanner families owning of cultivable
land are eligible.

2. Beneficiaries will get government support price, Kisan Future Bank Canteen Smart Card,
Fertilizers and Seeds for minimum price, Medical Facilities and Insurane etc.

3. Cut-off date is 1st March, 2022. No transfer of land, change of name, etc. after this date
shall be considered (except for change of name due to succession due to death).

4. Family" is defined as husband, wife and minor children. Husband, Wife or children cannot
claim the Scheme, benfits separately. In case of Joint Ownership of land by different
related families, then they will be eligible.

5. Tenants/Encroachers entered in Dag Chitha are not eligible.

6. Exclusion Criteria for farmer families with one or more of its members belonging to one of
the following:
i) Former and present holders of constitutional posts.

ii) Former & present Ministers, MPs, MLAs, Chairpersons of Municipal councils, Adhyaksha.

iii) Government employees (except Grade-IV employees).

iv) Pensioners with monthly pension of Rs.10,000 or more.

v) All persons who paid Income Tax in last assessment year.

vi) Professionals like Doctors, Engineers, Lawyers, Architects, etc., carrying out profession by
undertaking practices.

7. Documents required:

i) Updated Jamabandi (as of January 2020).

ii) Aadhar Number or Aadhar enrolment number.

iii) Other valid I-card like Driving Licence, Voters' ID card, NREGA Job Card (if Aadhar not

Available).

iv) Bank details (Account No. Bank Name & Branch, IFSC Code etc.).

v) 1 passport photo.