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    Instapdf - in Balika Samridhi Yojana Bsy Application Form 453

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    vaibhav_M_123
    This document contains an application form for obtaining a post-birth benefit of Rs. 500 under the Balika Samridhi Yojna (BSY) or Girl Child Prosperity Scheme for urban areas. The form requests information such as the name and address of the applicant mother and newborn girl child. It authorizes opening a joint bank account in the child's name and depositing the benefit and future scholarships. The form also has sections for verification of the applicant's details, sanction of the benefit amount, receipt for depositing the money and opening the account, and receipt for accepting the application.

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    Download as PDF, TXT or read online from Scribd

    Instapdf - in Balika Samridhi Yojana Bsy Application Form 453

    Uploaded by

    vaibhav_M_123
    23 views6 pages
    This document contains an application form for obtaining a post-birth benefit of Rs. 500 under the Balika Samridhi Yojna (BSY) or Girl Child Prosperity Scheme for urban areas. The form requests information such as the name and address of the applicant mother and newborn girl child. It authorizes opening a joint bank account in the child's name and depositing the benefit and future scholarships. The form also has sections for verification of the applicant's details, sanction of the benefit amount, receipt for depositing the money and opening the account, and receipt for accepting the application.

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    applicaiton form

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    Instapdf.in Balika Samridhi Yojana Bsy Application Form 453

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    This document contains an application form for obtaining a post-birth benefit of Rs. 500 under the Balika Samridhi Yojna (BSY) or Girl Child Prosperity Scheme for urban areas. The form requests information such as the name and address of the applicant mother and newborn girl child. It authorizes opening a joint bank account in the child's name and depositing the benefit and future scholarships. The form also has sections for verification of the applicant's details, sanction of the benefit amount, receipt for depositing the money and opening the account, and receipt for accepting the application.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    23 views6 pages

    Instapdf - in Balika Samridhi Yojana Bsy Application Form 453

    Uploaded by

    vaibhav_M_123
    This document contains an application form for obtaining a post-birth benefit of Rs. 500 under the Balika Samridhi Yojna (BSY) or Girl Child Prosperity Scheme for urban areas. The form requests information such as the name and address of the applicant mother and newborn girl child. It authorizes opening a joint bank account in the child's name and depositing the benefit and future scholarships. The form also has sections for verification of the applicant's details, sanction of the benefit amount, receipt for depositing the money and opening the account, and receipt for accepting the application.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 6

    BALIKA SAMRIDHI YOJNA (BSY)

    APPLICATION FORM FOR OBTAINING THE POST-BIRTH BENEFIT OF Rs.500/-


    (FOR URBAN AREAS)

    (No document other than the application form is necessary for obtaining the post birth benefit
    of Rs.500/-)

    To

    Civil Surgeon / Medical Officer Incharge


    ___________________________Municipality.

    Subject:- Balika Samridhi Yojna – application for obtaining the post – birth benefit
    of Rs.500/-.

    *********
    Madam/ Sir,

    I have given birth to a girl child. Details are furnished below :-


    1. Name of applicant (Mother) _____________________________________________

    2. Name of housband ____________________________________________________


    son of ______________________________________________________________

    3. Full address : House number ____________ Street ____________________


    Locality ________________________ Village ______________________________
    Block/ Tehsil/ Taluk __________________________ District __________________

    4. Date of birth of applicant (Mother) _______________________________________

    5. Date of birth of newborn girl child _______________________________________

    6. Place of birth of newborn girl child _______________________________________

    7. Name of newborn girl child _____________________________________________

    8. Number of girl children in the family already benefited under BSY excluding the
    newborn girl child ____________________________________________________

    9. Whether belonging to i) SC ____________________ ii) ST ___________________

    iii) OBC __________________ iv) Others ________________

    2. It is requested that the post-birth benefit of Rs. 500/- under BSY may be
    sanctioned in favour of my above named newborn daughter.

    Authorisation :
    I hereby authorize the implementing agency for BSY to open an interest-
    bearing account in the joint name of my new born daughter above and the implementing
    agency in a bank or post office nearest to me and, subject to the adjustment to be made as
    requested below (if any), to deposit the post- birth benefit therein. The BSY benefit of annual
    scholarships when the girl child starts attending school may also be deposited in the same
    account which will mature and become payable to the girls child on her attaining the age of
    eighteen years, subject to her having remained unmarried till then. No pre-mature withdrawal
    from this account will be permissible, in the event of the girl child having married before
    attaining the age of eighteen years, the amount at credit in the account attributable to annual
    scholarships and the interest accrued thereon shall stand forfeited and will revert to the
    implementing agency. In the contingency of the death of the girl child before attaining the
    age of eighteen years, the entire amount at credit in the account shall stand forfeited and will
    revert to the implementing agency.
    Adjustment requested to be made :

    An amount of Rs.__________ (Rupees ___________________________ only)


    may be paid to me in cash from the post-birth benefit of Rs. 500/- being the premium
    deposited towards the Bhagyashree Balika Kalyan Bima Yojna policy number
    _____________ taken in the name of the girl child above. Receipt number
    _________________ dated ______for payment of the insurance premium is enclosed
    herewith in original (to be enclosed by applicant).

    2. The amount of Rs.____________ (Rupees _________________________


    only) remaining after allowing the above adjustment from the post-birth benefit may be
    deposited in the interest-bearing account as per the above authorization.

    Signature of applicant-mother
    Date: ___________

    Place: ______________
    Verification And Report:

    Verified and reported that:

    1. Smt. _____________________wife of Shri_________________________ of House


    Number_________ Street ________________Town/ City _____________________
    has given birth to a girl child on (date) ________________ as per Birth Register/ Birth
    Certificate.
    2. The girl child has been given the following immunization: BCG/ Measles/ DPT/ Polio.
    3. The family of Smt._____________ wife of Shri_________________ of Town/
    City_____________ has been shown at serial number __________________ in the list
    of families below the poverty line under (name of BPL survey__________________.
    OR, The family is a BPL family as per the criteria mentioned in BSY guidelines.
    4. The total number of beneficiaries in the family under BSY including the newborn girl
    child above is _______________________.

    Urban Anganwadi Worker/ Multi


    Purpose Health Worker (Female)/
    Health Supervisor (Female)/
    Revenue Officer/ Municipal
    Officer
    Place __________________
    Date __________________

    Signature of Secretary/
    Executive Officer
    Municipality
    Place __________________
    Date __________________
    SANCTION

    This is to sanction Rs.500/- as post-birth benefit in favour of (new born girl


    child)________________ daughter of Smt. ________________________________ wife of
    Shri __________________________ of Town/ City _____________________ under BSY.
    The sanction has been approved/ vill be retified by a resolution of the Municipality. This
    sanction order will be notified on the notice board of the Municipality .

    Signature
    Secretary/ Executive Officer
    Municipality
    Place : _________
    Date : _________

    In pursuance of the above sanction, an interest-bearing account has been


    opened in the joint name of the newborn girl child above and (name and designation of the
    officer of the implementing agency)_____________________________________and the
    passbook for the same has been handed over to the applicant (mother of the newborn girl
    child) as per the details below:-
    1. Name of bank or post office where account opened ________________________.
    2. Date of opening of account ___________________________________________.
    3. Deposit scheme under which account opened and number of account opened
    _____________________________.
    4. Amount deposited : Rs.____________ (Rupees _______________________only)
    5. Passbook number __________________________________________________.
    6. Amount paid in cash to applicant (mother) as reimbursement of insurance premium as
    per the application : Rs.________________ (Rupees
    _____________________________ only)

    Name designation & Signature


    of officer of implementing authority

    Place : _________
    Date : _________
    RECEIPT

    Received the following from be implementing agency:-

    1. Cash amount of Rs.____________ (Rupees__________________________ only) as


    reimbursement of insurance premium as per the application.
    2. Passbook number __________ for Rs._________ (Rupees _________________ only)

    Signature of applicant
    (mother)

    Place : _________
    Date : _________

    Note:- Model forms relating to BSY benefit of annual scholarships when the girl child starts
    attending school will be devised and circulated to State Governments/ Union Territory
    Administrations.
    Urban Area

    RECEIPT

    Received application for obtaining the post-birth benefit of Rs. 500/- in favour
    of (name of newborn girl child) ________________________ from
    Smt._____________________ wife of Shri _____________________ of Town/
    City___________________________ on _________________.

    Urban Anganwadi Worker/ Multi


    Purpose Health Worker (Female)/
    Health Supervisor (Female)/
    Revenue Officer/ Municipal
    Officer
    Place __________________
    Date __________________

    Note :
    1. Please approach the Ward Councillor/ Chairperson, Municipality if the time taken in
    providing the benefit of Rs.500/- exceeds 90 days from the date of application.
    2. Please enclose a copy of this receipt alongwith with the complaint regarding delay.

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