ANNEXURE III
Farmers Eligibility Verification Form
NAME:
(As per Portal)
AADHAAR CARD: Yes No
If Yes Please provide below Details as per Aadhaar Card:
NAME:
(As per Aadhaar Card)
ADDRESS:
(As per Aadhaar Card and with PIN
Code)
Bank Account Details:
NAME:
(As per Bank Account)
BANK NAME:
BRANCH NAME:
IFSC CODE:
ACCOUNT NUMBER:
ACCOUNT TYPE: Savings Account
Basic Savings Account
Jan Dhan Savings Account
Loan Account (CC/KCC/OD/TL)
FD/Recurring Deposit Account
Any Other Account
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ANNEXURE III
Answer the following with Yes or No.
1. Has the farmer received his/her entitlement under PM-KISAN? Y N
2. Does the farmer/family member paid income Tax in last assessment year? Y N
3. Does the farmer/any family member fall in any of the following categories? Y N
b) Service or retired officer and employee of Central/State Government Ministry/
Office/Department and its field unit / Central or State PSE and attached offices/
Y N
Autonomous institution under Government / Regular employee of local bodies
(Excluding Multi-Tasking Staff/Class IV/ Group D Employees)
c) Superannuated/Retired pensioner whose monthly pension is Rs.10,000 or more Y N
(Excluding Multi-Tasking Staff/Class IV/Group D Employees)
a) 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 Panchayat?
Y N
d) Former/present holder of any constitutional post. Y N
e) Professionals like Doctors, Engineers, Lawyers, Chartered Accountants and
Architects registered with professional bodies and carrying out professions by
undertaking practices. Y N
Note: Please provide photocopy of Self attested Aadhaar Card and Front page of Bank Passbook.
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ANNEXURE III
Verification report for eligibility criteria under PM-KISAN Scheme
Sl. Required information Details
1 Name of the beneficiary
2 Father’s Name
3 Mother’s Name
4 Address (with PIN Code)
5 District
6 Name of Revenue Village
7 Name of Revenue Circle
8 Age
9 Gender
10 Category
Gen SC ST
11 Religion
12 No. of dependants in the family
13 Head of the family
14 Land holding details (If Applicable) Dag No.:
Patta No.
Area: Bigha Katha
Lessa/Chataka (in Barak valley districts)
15 Boundaries of the land mentioned above East:
(Optional) West:
North:
South:
16 From which year the beneficiary is
cultivating on the said land.
(Optional)
17 For how many years the beneficiary is
cultivating on the said land.
(Optional)
18 Name of crop cultivated
19 Ownership of the land (Wherever Self/ any family member/ taken on lease/ any
applicable) other.
20 Name of the land owner (Wherever
applicable)
21 Relationship with the beneficiary
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ANNEXURE III
22 Category of land (Please mention category as per Notification No.
AGA.242/2021/1 dated 12th August, 2021
Declaration: I hereby declare that the above stated information is true to the best of my knowledge
and
i) I am sharing my Aadhaar Card with my own consent as a proof of KYC to be used for PM-
KISANbenefit purpose only.”
ii) I do not have on Aadhar Card. However, I have submitted self attested copy of Driving
licence/ Voter’s ID Card/ NREGA Job Card/ Other photo identity Card issued by Central/
State/ UT or their authorities as valid KYC documents for the purpose my identity
verification.
Please strike out whichever is not applicable.
Signature or Thumb Impression of the Beneficiary:
Decision on beneficiary Eligible Ineligible
Report submitted by
Gaon Burha/ Village Headman Lot Mandal
Name with Seal & Signature Name with Seal & Signature
Agriculture Dev. Officer Revenue Circle Officer
Name with Seal & Signature Name with Seal & Signature
Note: All the above members are to mandatorily sign this document.
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