APPLICATION REFERENCE NO.

ANNEXURE I

PM-KISAN
KISAN NEW BENEFICIARY REGISTRATION FORM (ASSAM)
(APPLICATION-CUM-SELF
SELF DECLARATION FORM)

IMPORTANT NOTE:

1. Please fill the form in BLOCK LETTERS with Black/Blue ball point pen only and tick boxes where applicable.
Do not leave any field blank, instead
in mention Not Applicable
pplicable (N
(NA).

2. Avoid any sort of alterations/overwriting

alterations/ in the form.

3. Produce original documents for verification against each self attested photocopy by Applicant.

Farmer’s Personal Details Date: D D M M Y Y Y Y

1. Area Type : Urban Rural
2. District :
3. Sub-District :
4. Block/ Ward :
5. Village/ Town :
6. Farmer Name :
(As per Identity Proof Document)
7. Father/Mother/Husband name :
8. Gender : Male Female Other
9. Category : General/Others SC ST
10. Farmer Type : Small (1-2 Ha) Marginal (<1 Ha) Others
11. Number of dependants in the :
family
12. Name of Head of the Family :
Farmer Identity Details
13. Select ID Type : Aadhaar Other ID Proof
14. Type of Identity Proof : PAN Card Voter ID Driving Licence Ration Card
(in case of other than Aadhdaar) Kisan Credit Card
ard Passport No Bank Account No.
No
15. Identity Proof No. :
(as mentioned on the selected ID Proof)
16. Residential Address as per ID :
Proof (with PIN code)

Farmer’s Own Bank Account Details

17. IFSC Code :
18. Bank Name and Branch :

19. Account Number :

20. Account Holder Name :

21. Type of Bank Account :

(e.g.: Savings, Jan Dhan, etc.)
etc
22. Is Bank Account Linked with : Yes No
Aadhaar?
23. Mobile Number :
24. Date of Birth :

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Farmer’s Cultivable Land Holding Details
25. Land Holding Type : Single Joint
Cultivable Land Holding Details: (add more row if required)

Sr. Survey/ Khata No/ Patta No Dag/ Khasara No. Area (in Bigha-Katha-Lessa)
No.

26. Cultivable Land Address :

District :
Revenue Circle/
Circle Ward :
Village Town
Village/ :
PIN :
27. Cultivating on the said land :
(Since which year)
28. Name of Crop Cultivated :
29. Ownership of the land : Self Any family member Taken on lease Other
30. Name of Land Owner :
31. Relationship with Land owner :
(if land owner is different)

Self Declaration
I, Shri/Smti………………………………………………………………………………………………………………………………
Shri/Smti………………………………………………………………………………………………………………………………,, an applicant for income support scheme under
Pradhan
dhan Mantri Kisan Samman Nidhi (PM-KISAN)
(PM KISAN) scheme hereby declare and solemnly affirm that I am a farmer engaged in cultivation.

I further declare the following:

1. I am not an Institutional land holder.
2. None of my family members belongs to the following categories:
2.1. Former/present holder of any constitutional post.
2.2. Former and present Minister/State Minister and former/present Member of Lok Sabha/ Rajya Sabha/State Legislative Councils,
former and present Mayor of Municipal Corporation, former and present Chairperson of District Panchayats.
2.3. Serving or retired officer and employee of Central/State Government Ministry/ Office/Department and its field unit / Central or State
PSE and attached offices/ Autonomous institution under Government / Regular employee of local bodies (Excluding Multi-Tasking
Multi
Staff/Class IV/ Group D Employees).
Employees)
2.4. Superannuated/Retired pensioner whose monthly pension is Rs.10,000/-
Rs.10,000 or more (Excluding Multi-Tasking
Tasking Staff/Class IV/Group D
Employees).
2.5. Persons who paid Income Tax in last assessment year.
2.6. Professionals like Doctors, Engineers, Lawyers, Chartered Accountants and Architects registered with professional bodies and
carrying out professions
essions by undertaking practices.
2.7. Non Resident Indian (NRI) in terms of provisions under Income Tax Act, 1961.

3. ***I, Shri/Smti……………………………………………………………………………………………………….
Shri/Smti………………………………………………………………………………………………………. also give my consent and agree that the department
responsible for implementation of the Pradhan Mantri Kisan Samman Nidhi Yojana in the Union/State State Government can use my Aadhaar
Aadha
number and other information provided in the declaration to verify my eligibility as per extant scheme guidelines with concer
concerned
ned agencies.

4. I, Shri / Smti………………………………………………………………………………………
…………………………………………………………………………………………….. also declare that I have not availed the PM-KISAN
KISAN benefit
or any of its instalments before.

5. I declare that all the statements made in the application form are true and complete to the best of my knowledge and belief and a 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.

6. In case of incorrect self declaration made by

by me, I shall be liable for recovery of the transferred financial benefit and
nd shall be liable to be
punished as per law of the land.

*** Strike off if not applicable.

Signature or Thumb Impression of the applicant

Place:

Date:

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Field Verification Report (For office use only)

Verification Status: Verified Not Verified

Statements verified are found to be: TRUE/ FALSE on field verification.

Decision on Beneficiary : Eligible Ineligible

Remarks (if any) :

Report Submitted By:

Gaon Burha/ Village Headman/ Gram Sevak/Gram Lot Mandal

Sevika/Senior Gram Sevak/Senior Gram Sevika

Name with Seal & Signature Name with Seal & Signature

Agriculture Extension Assistant (AEA) Agriculture Development Officer

Name with Seal & Signature Name with Seal & Signature

Revenue Circle Officer

Name with Seal & Signature

Note:
All the above members are to mandatorily sign this document.

Application Reference No shall be fixed by district locally for tracking the application forms being received.

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APPLICATION REFERENCE NO.
……………………………………………………………..ACKNOWLEDGEMENT………….………………………….…………………
Received the duly filled in Application-cum-Declaration form with Application Reference
No…………………………………..for availing benefit under PM-KISAN scheme from
Shri/Smti………………………………………………………………………………………R/o……….…………………………………………………………
on Date (DD/MM/YYYY): DD/MM/YYYY along with the following self attested documents:

Valid KYC documents: a) Aadhaar Card as far as possible.

b) Other KYC documents like PAN Card, Voter ID card, Driving License, Ration Card, Kisan
Credit Card (KCC A/c passbook 1st page), Copy of Passport.

Bank A/c details : Aadhaar linked active Savings Bank account details: 1st page of the Bank passbook with
correct Name of the beneficiary, Bank A/c number, IFSC Code, Bank Name, Bank Branch etc.

Place:

Date: (Delegated authority)

For District Agriculture Officer

District:

Office seal:

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