Pradhan Mantri Kisan Samman Nidhi (Pm-Kisan) (Registration Form)

RECEIPT NO.
DATE / /
PRADHAN MANTRI KISAN SAMMAN NIDHI (PM-KISAN)
(REGISTRATION FORM)
1. District: 2. Sub-Division: Paste Self

3. Circle/Tehsil Block: 4. Block: Attested
Passport
5. Name of the Municipality/Gram Panchayat/Village: Size
6. Full Name of the farmer (in Capital) : Photograph
7. Date of Birth: / / Day(DD)/ Month (MM)/ Year (YYYY)

8. Gender: (Male/ Female/ Transgender): 9. Marital Status:
10. Father’s/Husband’s Name:
11. Mobile Number: 12. Aadhaar No.
13. ID Proof submitted: 14. Card No
15. Residential Address (in block letters) :
Pin Code:
16. Category (SC / ST / OBC/GENERAL):
17. Details of family members:
Name of the Family member Date of Aadhaar No. Relation to the Any land holding
birth applicant in his/her name
18. Details of Collective land holdings :

A) Type of land holding: Community Based / Private (Please specify):
B) Particulars of collective land holdings
SL. Name of the Pattadar Name of the *CS *Patta No. Area ( in *Any Co-
No. Revenue Village DAG No. Hectare) Pattadar ( in
Of Holding or case of joint
share holdings)
indicating
their shares
TOTAL
*in case of community based/privately owned land holdings (prevailing in hill districts), the areas of such land
holding/list of eligible beneficiaries/Exclusion criteria shall be certified/verified by the concerned Village Chief/ Chairman of
Village authority by way of declaration for the beneficiary concerned indicating share out of the total area owned by the
community/private and in such cases, CS Dag No & Patta No. may be dropped and name of joint owners may be indicated in
place of Co-Pattadars. Such reports shall be authenticated by the SDOs concerned.
Page 1 of 2
19. Bank details of the farmer/applicant
i. Name of the Bank Branch:
ii. Name of Account Holder:
iii. IFSC Code :
iv. Account number :
19. Exclusion Criteria:-.
i) Former and present holders of constitutional posts: Yes/No
ii) All serving or retired Class-I/II/III officers and employees of Central/
State Government PSU/Local Bodies/ Autonomous Institutions under Government: - Yes/No
iii) Monthly pension more than Rs. 10,000/- per month:- Yes/No
iv) Income Tax Payee: Yes/ No
v) Former and Present Minister/State Minister/MP/Ex -MP/MLA /
Ex-MLA / Mayor/Ex-Mayor/Zila Parishad chairman/Ex-Zila Parishad Chairman: - Yes/No
vi) Doctors/Engineers/Lawyer/Charted Accountant/Architects registered
with professional bodies: - Yes/No
SELF- DECLARATION
I, Shri/Smt/Km...........................................................................................................................
s/o,d/o,w/o,h/o........................................................................................................................................a resident
of....................................................................................................................under Tehsil:.............................
Sub-Division:......................... District:.............................. do hereby declare that I am a Small/ Marginal farmer
having less than 2(two) hectare of total collective land holding(s) in the name of my family ; and therefore eligible
for availing benefits under PRADHAN MANTRI KISAN SAMMAN NIDHI (PM-KISAN) Scheme.
2. That, all the statements made in the application form are true and complete to the best of my knowledge
and belief and 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. That, I
further declare that I do not fall under any of the exclusion criteria from being a beneficiary to the Scheme.
3. In case of incorrect self declaration made by me, I shall be liable for recovery of the transferred financial
benefit and shall be liable to be punished as per law of the land.
4. ***Further, I also give my consent and agree that the department responsible for implementation of the
Pradhan Mantri Kisan Samman Nidhi Yojana in the Union/ State Government can use the beneficiary Aadhaar
number and other information provided to verify the eligibility of the undersigned for the Scheme.
Date: Signature / Thumb impression of the farmer:

Place: Name:
Address:
FIELD VERIFICATION REPORT
Name of the Verifying Officer/ Official/ Authority:
Date of verification:
Statements verified and found to be: TRUE / FALSE on field verification.
Recommendation: ELIGIBLE/ INELIGIBLE
Remarks (if any):
Date: Signature of the Verifying Authority:

Place: Name:
Designation:
*** Strike off if not applicable
Page 2 of 2
,
<iU IDELlNES FOR PM· KI SAN
!. New Scheme fo r all small and marginal landholding fanne r families owning up to 2 Ha of cultivable
land are eligible. The total of all land in different revenue villages must be less than 2 Ha.
2. Beneficiaries will get Rs. 6,000/- per year in 3 instalments (@ Rs. 2,000/- per instalment). The
instalment fo r Dec 2018-Marth-2019 will be paid by March.
3. Cut-off date is pi February, 2019. No transfer of land, change of namc, etc. after this date shall be
considered (except fo r change of name due to succession due to death).
4. " F~ily" is defined as husband, wife and minor children. Husband, Wife or children cannot claim the
bcl,efits separately. In case of Joint Ownership of land by different related families, then they will be
eligible if their shares are less than 2 Ha
5. TenantslEncroachers entered in Dag Chitha are not eligible.
6. Exclusion Criteria for fanne r families with onc or marc of ilS members belonging to one of the
following:
i) Fonner and present holders of constitutional posts.
ii) Fonner & present Ministers, MPs, MLAs, Chairpersons of Munic ipal councils, Adhyaksha.
iii) Government employees (except Grade-IV employees).
tv) Pensioners with monthly pension of Rs.IO. 000 or more.
v) All persons who paid Income Tax in last assessment year.
vi) Professionals like Doctors, Engineers, Lawyers, ArchitcclS, etc., carrying out profession by
undertaking practices.
7. Documents required:
i) Updated Jamabandi (as of January 2019).
ii) Aadhaar Number or Aadhaar enrolment number.
iii) Other valid I-card like Driving Licence, Voters' 10 Card, NREGA Job Card (if Aadhaar not
available).
iv) Bank detai ls (Account No.lBank Name & Branch, IFSC Code etc.).
v) I passport photo.

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RECEIPT NO.

1. District: 2. Sub-Division: Paste Self

7. Date of Birth: / / Day(DD)/ Month (MM)/ Year (YYYY)

18. Details of Collective land holdings :

Date: Signature / Thumb impression of the farmer:

Date: Signature of the Verifying Authority:

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