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FORM
XVIII
Form
of Declaration
(See Rule 45A of A.P.G.S.T.
Rules, 1957)
To
Sri/M/s
______________________________
______________________________
______________________________
Sir,
I___________________________________________________________________________Son
of
_____________________________________________________________________________________
(address)
hereby declare that today on the _____________________ (date), I have entrusted
you with a quantity _____________________________ (in Metric Weight) of paddy
belonging to me for conversion into rice in your rice mill.
The
above mentioned paddy
(i)
was grown on my own land, the particulars of which are given below:
|
Name
of the Village where the land is situated
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Extent
of land on which the paddy was grown.
|
Total
yield of Crop
(Kilograms)
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1
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2
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3
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(ii)
was received by me towards rental from my tenant to whom the land was
leased out.
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Name
and Address of the
tenant.
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Extent
of land
which
was given
on
lease.
|
Name
of the Village
in
which the land leased is
situated.
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Total
Quantity
received as rental
(Kilograms)
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1.
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2.
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3
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4.
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(iii)
was grown by me as a tenant of the land of
Sri/Srimathi
__________________________________
___________________________________
___________________________________
___________________________________
(Name and
address) the particulars of which are as below:
|
Name
of the village in which the land is taken
on
lease
|
Extent
of land taken on lease
|
Total
yield of the Crop
(Kilograms)
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1
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2
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3
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(iv) was brought by me from Sri
_________________________________________________(Name), son
of____________________________________________________________________ residing
at
___________________________________________________________________________________(Address)
(v) was received by me from Sri _______________________________________________ (Name),
son
of____________________________________________________________________residing
at:________________________________________________________________________________
____________________________________________________________________________(Address)towards wages.
I declare that
what is stated above is true to the best of my knowledge and belief.
Place:
Date:
Signature of the person
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