The land of the Dancing Deer

  

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GOVERNMENT OF MANIPUR
DEPARTMENT OF SOCIAL WELFARE

FORM  B.S.Y
Application Form for Balika Sammidhi Yojna
(To be filled up by the applicant)
                                                                                                                                                                           

District :- 
1. Srimati :-
2. Name of husband:-
3. Full Home Address:-
4. Categories:- SC/ST/Woman/Landless/Handicapped/General.
5. Age on the date of the applicant :-
6. Date of birth of the girl child after 15-08-97 (Birth certificate have to be enclosed):
7. Identification mark of the applicant :-
8. I solemnly affirm that :-
   a. I belong to the list of below poverty line household in the village as defined by the IRDP, Manipur.
   b. This is my application with regard to FIRST/SECOND born girl child.
   c. I am a resident of …………………………………………………
     (District/State) where I have been residing during the three years immediately preceding the date of this 
     application.
  d. I declare that the information furnished in this application is true and correct to the best of my knowledge
        and belief .


Place :-                                                                              Signature of Thump impression
Date :-                                                                                         of the applicant



N.B :- Families to whom a girl child is born, in they are living below the poverty line on or after 15-08-97 will be eligible under the "Balika Sammidhi Yojna".
 

 

ENQUIRY TEAM
(To be filled up by the enquiry team)
  
1. Age :-
2. Income/Destination :-
3. Category, Domicile :-
4. Whether birth certificate furnished is genuine or not :-
5. Whether the application belongs to below poverty live household:-
6. Recommendation :-


Date :-                                                                                Signature of the Verifying person
                                                  Municipal Councillor/Members of Zilla Parishad/Pradhan of Gram Panchayat/
                                                                                Village Authority//AnganwandWorkers/VLWS.
                                                                                          

                                                                                          Full address :-

Note :- This application along with full particulars, documents etc. should be submitted either to the District Social Welfare Officer of the District concerned or to be the Child Development Project Officer of the concerned C.D/T.D Blocks.

________________________________________________________________________________
Recommendation of the District Social Welfare Officer/ Child Development Project Officer:-

 


                                                                                                 Signature of B.D.O/C.D.P.O, ICDS Project