FoRM- 3 (ACLAIM FOR DOTTED LANDS COVERED UNDER SUB SECTION (3) OF SECTION 4 OF THE ACT) [See Sub- Section (2) of section 6 of the Act and Rule 3(c)] To The District Collector and Chairperson, . ‘istrict Level Committee, Sx Sela Sai. citer state that the following. aad lands are in mfr eetionand enjoyment for the last...2.=1.. years. ‘we hereby declare that the land claimed by me/us as shown here under is not assigned land (or) used land. Sino Name of the ‘SyNo | Extentinacres | Mode of Remarks Village acquisition JT 2 3 a 3 é 4 Thurnmade | 13148, 5.00 | 2. Nhusnsnala | 1212-1 yok “we submit the following documents for kind perusal. a. Registered Documents with Document No end Date (allink Documents shall be provided) yes/no b. Entries in RH maintained by the Registration department copy ©. Encumbrance Certificate copy 4, 10(1) Adangal Copy €. ROR Record maintained by Revenue Department copy f. order or decree of any court / competent authority copy Yesine- fes/No- ares NG Me request that my/our name kindly bg entered in Re- Settlement Register and other Revenue Records and deleted from the Prohibitory properties list furnished to Registration Department u/s 22-1) of Registration Act 1908, wee: Aradaquis Nate: OU -0 5 -203-3 signature[s) of Iota ants) With address and Contact No. ‘Scanned wih CamScanner