The land of the Dancing Deer


                                                                                  ANNEXURE IV

FORM M.E......I

Application Form for Maternity Benefit I
(To be filled up by the applicant)

District :-                                                         Block/Panchayat/Samiti/Municipality

                                                                      Village/Panchayat/Mohalla/Ward/House No.

1. Srimati :-
2. Name of husband:-
3. Full Address:-
4. Categories:- SC/ST/Woman/Landless/Handicapped/General.
5. Age on the date of the applicant :-
6. Identification mark of the applicant :-
7. I solemnly affirm that :-
1. I do not have any family income of Rs. 5000/- per annum or more.
2. This is my application with regard to FIRST/SECOND pregnancy.
3. I am a resident of .
    (District/State) where I have been residing during the three years immediately preceding the date of this
4. I declare that the information furnished in this application is true correct to the best of my knowledge and
    belief .

Place :-                                                                       Signature of Thump impression
Date :-                                                                                  of the applicant
II (To be filled up by the enquiry team)
Results of preliminary Enquiry by the Village Panchayat Level team :

1. Age (19 years or above) :-
2. Income/Destination :-
3. Category, Domicile :-
4. Whether applying in case of the first/second pregnancy :-
5. Whether registered with the Primary HEALTH Centre/Health Centre:-
6. Whether the applicant belongs to poor family :-
7. Recommendation :-

Date :-                                                                         Signature of the Verifying person
                                                                                Municipal Councillor/Village Authority/
.                                                                                  Full address :-

Note :- This application should be sent with full particulars to the B.D.O/C.D.P.O, ICDS Project Concerned.


                              RECOMMENDATION OF THE B.D.O/C.D.P.O ICDS PROJECT


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

                                                  Countersigned by S.D.O concerned.