PRADHAN MANTRI KISAN SAMMAN NIDHI (PM - KISAN)

Application Form

Sub Division:..................... Block: .............................. Village:............................. Farmer’s Name:..............................................

................................................ Sex: Male [M] /Female [F]/Other [T]............. F/H Name:............................................................

AADHAR ID: IFSC Code

Bank A/C. Mobile:..................... D.O.B : / /

Category: SC[1] /ST[2]/BC[3]/OBC[4]/GEN[5].......... Address:..................................................................................................

Self Declaration: Yes/ No

I am an institutional farmer

Any family member ever held or holding a constitutional post

Any family member ever held or holding the post of MLA/MP/Mayor/ Chairman Zila Parishad

Any family member is /was serving or retired employees of central / state government (excluding class 4 employees)

Any family member is a Retd. Pensioner having a pension more than 10,000/- per month (excluding class 4 employees)

Any family member has paid Income Tax for assessment year 2018-19

Any family member is a registered Doctor/Lawyer/CA/Engineer/Architects practicing privately

Land Details
Khewat No. ................. Khasra No........................................ (*More land details, if any, may be written on back page)

Area (Hect. )..................................... Ownership: Single [1] / Joint [2]

Declaration by the applicant:

I....................................................S/o........................................R/o Village.......................................hereby declare that above
information provided by me is true to my knowledge, and if found incorrect, only I would be liable for the same. The total
cultivable land of my family as defined in operational guidelines of (PM-Kisan) in the country is less than 2 hectares.

Date & Place............................ Signature of Applicant.................................

Verified By Patwari Seal & Signature...................................

Permission to Use AADHAR Number:

I.................................................... S/o........................................ R/o Village....................................... hereby grant my

permission to use my AADHAR number for verification purpose under (PM-KISAN) scheme only.

Enclosed: AADHAR Copy - Yes No Bank Details Copy: Yes No

Date & Place:............................ Signature of Applicant..............

For Office Use

Application Accepted: Yes/No Data Entered: Yes/No

if No, Reason for Rejection:..................................................... Date: ............................
Verified By PS........................ Signature ....................................... DEO Name: ......................

Signatures:...................................