Application Form for Maternity Benefit I
District :- Block/Panchayat/Samiti/Municipality
|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
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