Application for Conversion of Land
(Court fee of Rs. 20/- to be affixed)
To
The District Land & Land Reforms Officer,
Sub : Prayer for conversion of land
Dear Sir,
I/We shall be very much glad if you kindly arrange to convert the following schedule of land
to Non-agri. land for setting up of Industrial/Housing Complex.

Schedule of Land
a) Name of Mouza : .............................................................................................................
b) J.L.No. : .............................................................................................................
c) Khatian No. (R.S.& L.R.) : .............................................................................................................
d) Plot No. (R.S.& L.R.) : .............................................................................................................
e) Recorded Classification : .............................................................................................................
f) Area of land : .............................................................................................................
g) Police Station : .............................................................................................................
h) District : .............................................................................................................
The following document in 5 copies are enclosed.
1) Declaration
2) Copy of Mutual Certificate
3) Copy of current Record – of – Right
4) Site Plan in duplicate.
5) Certificate regarding industries issued by the D.I.C./Dte. Of Industries/
Deptt. of Industry.
6) Copy of the Project report duly vetted by the Competent Authority.
I / We further undertake to the effect that I / We will have no claim over the said land if in future the land(s) vests in the State in any proceeding under any provision of law.
I / we also undertake to the effect that if the land in question is found to be vested, I / We will apply to the State Government for Long Term Settlement of the same under usual terms and conditions on payment of Rent and Selami etc. as will be determined by the State Government.
That in case of my failure to apply for Long Term Settlement within the period of one month, I shall be
liable to be evicted from the land as a trespasser and shall also be liable to payment of damage for use and occupation of the said land.
That I have taken over possession of the land and the said land is free from encumbrances.
I / We also declare that none of the land is recorded as Tank/ Orchard or cultivated by Bargadar.
Date :.............................. Yours faithfully,
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