iA . “Porm 16" (See suberute (J) of rale SAA) onlisation for reguiarization of change of character, conversion or alteration in'the mode of use of plot of land) ROM: name and address of the npplicant(s)) Block Land and Land Reforms Offiger, Sud: Appitcation for regularization of elys of chataeter, conversion of alteration inthe-m of e plot of tend made in, violatlom-of the provision of sub-section(2) of section 4C of Bengal Land Reforms Act, 1955. : We have the honour to apply for regularization of change of charaeter, ebnversion or alteration in voile of use of the plot of land for the purpose of. partes oF the plot of land with resyest af whieh such regilorization is eq Lave fuinished Imus (1) Name of the District Name of the Blok Name of the police station we (3) Name ofthe Mowea f : (5) Jurisdiction List No, (6) Khatian No, (R.S. & LR.) (7) PlorNo.(R.S & LR : (8) Area of the pldt (R.S-& LR) q og (art ploy, spectly the aroa aid partion) (9) Existing Classification of the Plot + ‘The following documents, in duplicate, are enclosed with this application :- (\) Copy of mutation certificate or copy of current revbrd 6f rights, ! . 2) Copy-of current rent receipt. ; : ; s G» Sketch map-showing the plot in Question with side measurement and. its Surroundings Including ‘approach road (may not be fo the senle), i/We also declare and undertake — 1) That the plot of land, in question shall be used. strictly for the purpose: for whrich premises for-such regularization shall be granted; (2) That there is no bargadar, in the plot of land, in question; (3) That the fees vayable for sudh regulaslzation shall be deposited whihin 15 skijs fram the date of order, for such regularization; (4) ‘Thot no work shall be done on the plot of Jancl, in question that may lead (0 further conversion of the sane unless permission as sought for is grantse: (3) ‘That necessary approval or permission of [icense shall be obtdined from the appropriat sequired for execution of the work on the plot of land. in question as soar regularization as sought for granted; authority & - aS permission for such ‘That there is av other plot of land except the plot of land which has been changéd, converted or altered in violatign of the provision of sub-section (2) of section 4G-of the Acts 3. UWe further declare — (1) That the plot of land in question is under peaceful possession of myselfourselves arid itis free liom all encumbrances; ‘ 2) That the plot of fond in question is not involved in any proceeding for vesting under the provisions of any law, : : : ‘That the plot of land in question'is not involved in smy court case which prohibits regularization of such: change of character, conversion or alteration in the mode of use of the Ind, ~~ point oF time that the, doca-cenis furnished ‘inubove are not true and covert, MMe sanvcire JRablé for any leynt agtion which evill be dy the competent authority in this regard ineluding eaneetlation of or lesgranting regutort cer conversion ar alteration in the made afase of the plot of innd as souglit for. We also declare and undertake that in case f starements made he: is flow of.auich. chnige : \ s siuied abover Youis foith fully, (Full signature of the applieni(s With seal, if any ) Place a 2 Date By order of the Governor eis R.D, MEENA PiScey. to the Govt. of West Bengal: Prbrahae ve Tia RTSn / Sm, declare.es follows A ‘ Ba 10, u 1, Sui / Smt SS: uaa ara amcor — | J Foe Stamp son of I'daughter of cesnaidsnewnngnoenyien TOSLGING AC cLamawsusuneny WEE Polign Station and “Ther Iam the gbsolufe owner of the plot of the Tang decbrined'in the Sthedule bslow by way of transfer vide Registered Deed No. co dated T toheritaiice being the legal, heir of GUE 1S ’ “That T,hayer been possessing. thé sald:plot of land sirice and'ty is free from ell breumbrances. "= |, 8” 3 ‘That the faid plot of lénd is neither. vested nor-acquired by the Go proceeding Initlatcdl'in respect of the ssid’ plot of lend for.its vesting or acc 1 dées, not fall wader the puriew of the"Urbam Lend (Ceill “That the said plot of land is Hor vested ox ssegutucion), Abi 61S. “Thar the said:plot of land is not‘irivolvéd in ahy Court Case. “That { shall apply for long term settlement of the:ssid plot of land on sich terms and eonditica ane on payfnent of suet salami and ent asthe State Government may fx ip thls regard, if the’said slot of land is found to-haive already been vyested.in the State.at any point of timé, In case of failure to. do so, I ‘Shall, forthivith make over vacanit and-peaceable possession of tho’said plot df land.to ‘the State Government. * ‘That J shall make-over possession of the said plot of land to tht State-Government without any claim, if the said plot of land ia. found to. have.clready been acquired by the Siste Government at” any’ point, of time. . ‘That J shall pay regulerly the land revenue in respect ofthe said plot of lend-as may be fiked by the State Governinent ih. accordance Wwith the provision.of the West Belmal Land Reforms Act, 1955 fas amended from time to time, “i i Tat I shall abide by all the terms and conditions as may, be fixed by fle State’ Government from. ine to time for holding the suid plot of land.as per provision of any law for the timerbeing in Force. ‘That the mutation granted shall be lable to be tantelled if any formation providéd-with the ‘mutation application, is found to be not'truc:* : : ‘That the sjavements made hereinabove are true.t0, the’ best of my‘ information,.knowledge and belief and nothing material’ has been congealed therein, DESCRIPTION OF THE PLOT: OF LAND | District: FPotice Station. -Mouta with ‘Total da Si, No. > Whation-No.| | Plot.No. l'Ares dwned Full Signature of the Declarant