|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
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".
|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 :-