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Right to Fair Compensation and Transparency in Land Acquisition, Rehabilitation and Resettlement (Social Impact Assessment and Consent) Rules, 2014

Form - IV

Part - A. Prior Written Consent / Declaration Form

[See sub-rule (1) of rule 16]

S. No. Details of Person Concerned  
1. Name of the person(s) as per section 3(c) (i) & (v) of the Act:  
2. Name of the spouse:  
3. Name of father/ mother:  
4. Address:  
5. Village / Basti:  
6. Gram Panchayat / Municipality / Township:  
7. Tehsil/ Taluka:  
8. District:  
9. Name of other members in the family with age:
(including children and adult dependents)
10. Extent of land owned:  
11. Area for the acquisition  
12. Plot No.  
13. Record of Rights  
14. Disputed lands if any  
15. Pattas/ leases/ grants, if any  
16. Any other right, including tenancy, if any:  
17. Regarding the acquisition of my land by the government, I wish to state the following (please circle)  
(i) I have read/readout the contents of this consent form and explained to me in __________language and Yes No
(ii) I do not agree to this acquisition Yes No
(iii) I agree to this acquisition Yes No

Signature or Thumb impression of the affected family(s) and date:

18. The terms and conditions, Rehabilitation and Resettlement, compensation and other measures committed by the Requiring Body have been explained in the local language.
These terms and conditions must be attached to the Form.

Date and Signature of designated district official receiving the signed form

  It is a crime under law to threaten any person or to cause them any harm if they refuse to consent or if they choose to state that they do not consent on this form. This includes any threat or act that causes them to lose money, that hurts them physically or that results in harm to their family. If any such threat has been made this form is null and void.

Part-B. Format for Gram Sabha Resolution

[See sub-rule (6) of rule 17]

We, the undersigned members of the Gram Sabha of ___________ within ______________ panchayat of __________ tehsil/taluka in ___________ district wishes to state that the following certification is based on the information supplied by the administration and officials. If this information is incomplete or incorrect or if any consent has been obtained through any use of threats, fraud or misrepresentation, it is null and void. On this basis, this Gram Sabha hereby certifies that it CONSENTS / REFUSES TO CONSENT to the proposed _________ project, which will involve:

  • 3/4 acquisition of _________ acres of private land.
  • 3/4 transfer of ___________ acres of government land to the project.
  • 3/4 transfer of ___________ acres of forest land to the project.

The terms and conditions of compensation, rehabilitation and resettlements benefits and social impact mitigation measures agreed to by the Requiring Body (state the name) are attached.

The Gram Sabha also states that any consent is subject to all of its residents receiving title to all of their individual and community rights over forests and forest lands, including their titles for forest land that they have been cultivating, ownership titles for all forms of minor forest produce that they use, and titles to protect and manage their community forests.

[Note: This will have to be certified by this Gram Sabha separately.]


Date and signatures/thumb impressions of Gram Sabha members


Date and Signature of designated district officer on receipt of the Resolution

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