APPLICATION FORM FOR MAIN LOAN / LOAN PROMOTION SCHEME

RASHTRIYA MAHILA KOSH

1, Abul Fazal Road, New Delhi - 110001

APPLICATION FORM
FOR
MAIN LOAN/LOAN PROMOTION SCHEME

1. ORGANISATION DIRECTORY

(a) Name of the Organisation
(b) Address
(c) State
(d) District
(e) Block
(f) Phone No. (with STD Code)
(g) Fax No. (if any)
(h) Nearest Railway Station
(i) Registration no. of the Organisation
(j) Date of Registration
(k) Date of Renewal, if any
(l) Area of Operation :
(m) Name of the Bank of Organisation
(n) Account No.
(o) Name and Designation of Chief Functionary

2. Details of Executive Committee members

S.No.	Name	W/o or D/o or S/o	Designation	Address with Door no. / Street / Village / Town / District	Land line no. / Mobile no.
(1)	(2)	(3)	(4)	(5)	(6)

3. Details of Socio-economic Developmental Programmes conducted by the organisation during the last 3 years (year wise)

Year	Name of the Programme	Funded by	Amount received	Achievements
(1)	(2)	(3)	(4)	(5)

Note : Please enclose a copy of your annual reports of last three years.

For office use only :

4. Experience of the organisation in CREDIT Activity during last three years
(year wise). (Amount in Rs.)

Years	Amt. of loan outstanding from previous year (31.3. --	Amt. of loan disbursed during the year	Total =2+3	Demand amount , which was due for recovery as on ----	Amount actually recovered as on --	Over due as on ----- (5-6)	Percentage of recovery (%)	Outstanding at the end of the year 31.3.-- (4-6)
1	2	3	4	5	6	7	8	9

This statement is the consolidated figures of statement (5)

5. FORMAT OF DEMAND COLLECTION AND BLANCE REGISTER (DCB)

Loaning made to SHG members out of their own savings (Inter loaning)

Loaning made to SHGs out of the funds received from funding agencies.

Loaning made to SHGs from Bank where NGO acts as a facilitator.

Loaning made to SHGs out of own funds of NGO.

YEAR WISE (Last three years)

SL. No.	NAME OF SHG	Amt. of loan outstanding from previous year (31.3. --	Amt. of loan disbursed during the year	Total =3+4	Demand amount , which was due for recovery as on ----	Amount actually recovered as on --	Over due as on ----- (6-7)	Percentage of recovery (%)	Outstanding at the end of the year 31.3.-- (5-7)
1	2	3	4	5	6	7	8	9	10
1
2
3

Separate DCB statement for A, B, C, D, category has to be submitted by the NGO (year wise and SHG wise for last 3 years).

It should be tallied with other related statements/information furnished by the NGO, any.

“Nil” statement may be submitted regarding A or B or C or D if the NGO does not have any experience in under such category.

Note:- The details in S.No. (5) should tally with the books of SHGs and with the data maintained by NGO.

6. Experience of the organisation in thrift/savings and formation of SHGs. Please give details as below (Position as on _________________________). Detailed list SHG-wise

(Amount in Rs.)

Sl. No.	Name and Address of SHG	Date of Formation	No. of Members	Savings Mobilised	Loan given out of savings	Amount Received	Amount of loan outstanding
(1)	(2)	(3)	(4)	(5)	(6)	(7)	(8)




Total

Note:- The details S.No. (6) should tally with the books of SHGs and with the dta maintained by NGO.

7. Proposed lending programme in the current year

(Amount in Rs.)

Sl. No.	Category of Loan	Name of Activities	No. of SHGs	No. of Borrowers	Average amount of loan per beneficiary	Total Amount Required
(1)	(2)	(3)	(4)	(5)	(6)	(7)

8. Sources available with the organisation

(Amount in Rs.)

Sl. No.	Source	Balance at the beginning of year	Amount expected during the current year	Total amount
(1)	(2)	(3)	(4)	(5)
1.	Own Sources
2.	Savings of SHGs/members
3.	Recovery of loans from SHGs/members
4.	Other sources such as grants/donations, etc.
5.	Borrowings (other than this application of RMK)
6.	Total

9. Financial Assistance required from RMK (i.e. para 5-6)

(Amount in Rs.)

Sl. No.	Category of Loan	Name of Activities	No. of SHGs	No. of Borrowers	Average amount of loan per beneficiary	Total Amount Required
(1)	(2)	(3)	(4)	(5)	(6)	(7)

10. Financial position of the organisation as per Balance Sheet (As on .................)

(Amount in Rs.)

Liabilities Assets

Corpus fund Fixed Assets

Loan from Financial Institutions Loan to SHGs

Other Current Liabilities Other Current Assets

Total Total

(Details of borrowing if any, may be in the proforma below)

Name of the Lending Institution	Date Borrowed	Amount Repaid	Amount Outstanding	Balance of borrowings	Overdue, if any
(1)	(2)	(3)	(4)	(5)	(6)

(Copies of Sanction letters to be enclosed)

11. Organisational Set-up and Training

(i) Details of staff

No. of staff with the organisation	Trained	Untrained	Total
(1)	(2)	(3)	(4)
(a) Office/Supervisory Staff
(b) Field/Extension Staff
Total

(ii) Details of arrangements available with the organisation for training of Staff/SHGs.

12. Check List

S.N.	Details of Enclosures	Yes/No	Page No.
1.	Attested Copy of the Registration Certificate/Renewal
2.	Attested copy of MOA & Bye-laws
3.	Indicate the provision to borrow from outside agency
4.	Detailed Objectives of the Organization
5.	Details of Bio-data of the Chief Functionary experience in social sector
6.	List of current Managing Committee members duly attested
7.	Resolution for seeking credit assistance from RMK
8.	Consolidated audited accounts for the last 3 years
9	Annual Reports for the last 3 years
10	Copies of sanctions received from funding agencies/Govt. Departments etc
11.	Utilisation certificate received for funding agencies
12.	Undertaking to charge rate of interest not more than 18% NGO to SHG to ultimately beneficiary on reducing balance
13.	Undertaking to keep the registration of the organization alive during the currency of RMK loan
14.	Undertaking that office bearers should not be elected members of any political party
15.	Undertaking to inform RMK in case of changing address.
16.	If borrowed from other organizations, No Dues / Overdues certificate from funding agencies
17.	Details of Socio-Economic development activities implemented during the last 2/3 years
18.	Passport size photographs of the President, Secretary & Treasurer of the organization duly attested by a Gazetted Officer each photo to be attested individually.
19.	Certificate regarding proof of residence of the President, Secretary and Treasurer with their present and permanent address duly attested by a Gazetted Officer
20.	Details of arrangements available for organizing training for its Staff/SHGs
21.	Copy of resolution in case of dissolution of the organisation / Undertaking Rs. 50/- for dissolution clause
22.	Clause of 2/3^rd quorum in MOA byelaws.
23.	DCB for the last three years

DECLARATION

I________________________(Full Name with Designation) certify that the facts and figures furnished in the application form and the annexures are correct and tally with the records of our Organisation and any concealment of facts/misrepresentation/indulgence in illegitimate practices which are violative of the terms of sanction and as a consequence thereof, the Rashtriya Mahila Kosh is put to monetary loss, will render me liable to be proceeded against under the relevant provisions of the law of the land.

Place:

Date: (Signature with official stamp)

Encl.: Name & Designation of

chief Executive