FORM-3

(A CLAIM FOR DOTTED LANDS COVERED UNDER SUB SECTION

(3) oF SECTION 4 OF THE ACT)
See Sub- Section (2) of sectlon 6 of the Act and Rule 3(c)
TO
The District Collector and Chairperson,
District Level Committee,
Sadtrpa.sai. District.
Sir,

/we...xiMEUS/o, D/o, W/o .R/o Vilage...Mandal.kl.pa:District

state that the
following dotted lands
are in my/our possesslon and
enjoyment for the last.. years.
1/we hereby declare that the land claimed by me/us as shown here under is not assigned land (or)
leased land.

Sl.no Name of the SyNo Extent in acres Mode of Remarks

Vilage acquisition

Annadaiu 153 o Je

we submit the following documents for kind perusal.

a.
Registered Documents with Document No and Date ( all link Documents shall be provided)
yes/No
b. Entries in RH maintained by the Registration department copy
c. Encumbrance Certificate copy
yès/No
d. 10(1) Adangal Copy
ves/No
e. ROR Record maintained
ves/No
by Revenue Department copy Yes/No
f. order or decree of any court /
competent authority copy Yes/No

IWe request that my/our name kindly be entered in Re- Settlement

Register and other Revenue
Records and deleted from the Prohibltory properties list furnished to
Reglstration Department
u/s 22- A(1) of Registration Act 1908.

Signature(s) of the claimant(s)

With address and Contact No.

Place:ArnO dogR9
Date:
3- t -202L
ENCI: All relevant Documents to be enclosed