* Govt.

of Kerala - Oct 2016 * Applicant to fill in the RPIS Registration Number, if applying for Transfer of Registration or Addition/Reduction of Area

For RPS use only

Inward No. & Date

RUBBER PRODUCTION INCENTIVE SCHEME

Application form for Registration of Rubber Grower

(vide G.O. (P) No.269/2015/Fin. Dated 03/07/2015, GoK)
Reg. No: RUBRUBXXX
one registration only is permitted for each applicant
New Registration Transfer Area Addition
Name of Applicant
(As per documents)
Name of (tick the applicable)
Father Mother Husband
Date of Birth
D D M M Y Y Y Y

For
New Registration
or Transfer,
paste passport size
photographs
(of all owners, if
jointly held)

Mobile No.

Photo Id Card No. Aadhar

Gender

Male Female Other

RPS Member/RB Permit No.

Address with House No. & House Name

District
State
PIN Code

A/c No.

IFSC

Bank

Branch

Bank A/c Type Single

Joint

Own Land PAH Legal Heir Possession - Single Joint

Details of all the Rubber Holdings Owned by the Applicant in all the districts- furnish latest LTRs/proof
Year of
Area (Ha)
No of
Clones
Taluk
Village
#Acquired
Planting
Trees
from RRNo.
Total
Tapping

Total
# RR No. & Name, if purchased/inherited from RPIS beneficiary
Attach Annexure-I for Joint Owners/PAH/Legal Heirs/Joint Account and Annexure-II for undivided land.
Enclosed Id-Proof DoB Proof LTR . Nos Passbook-IFSC/Ac No. Annexure-I Annexure-II
Declaration by the Applicant
I hereby declare that the information furnished above is complete and correct to the best of my knowledge and belief.
I understand that if at any stage the details provided are found to be false or incorrect, I am liable to refund the total
incentive received under this scheme.

Date:

Signature of Applicant
Recommendation by the RPS President

I hereby certify that the information furnished by the applicant has been verified. I recommend registering this
applicant under the scheme through my Rubber Producers Society. I agree to make arrangements for uploading the
required details in the scheme website. The details furnished by the applicant will not be disclosed to any other person
without the consent of the applicant for any other purpose.

Date:
Name & Signature of RPS President
Recommendation/Remarks of Rubber Board Officer
Application Status Confirmed Rejected (Give reasons below)
Date:
Name & Signature of RB Officer
Documents to be attached - copies of (i) Aadhar Card (ii) Land Tax Receipts for all holdings (iii) Bank Passbook
showing the latest IFSC & Acc No. (iv) Verification Report of RB Officer (if Joint/PAH/Legal heirs/Undivided etc)
#If acquired from an RPIS beneficiary, consent for reduction of area by the original beneficiary is required.