NSTFDC FORMAT NO.3 FORMAT OF APPLICATION FOR FINANCIAL ASSISTANCE FOR TRANSPORT SECTOR (THIS IS ONLY A FORMAT AND NOT AN APPLICATION FORM) 1. DETAILS OF PROMOTER(S): a) Name & Address of the Promoter(s) : b) Constitution: Proprietorship/Partnership/: Cooperative Society (Attach documentary support) c) Present activities of Promoter(s) 2. PROPOSED ACTIVITY : a) Name of the Scheme: b) No. of Unit(s) : Rural : Urban : Total : c) No.of Beneficiaries: Per Unit Total For...Units (Owners of Assets only) ------------------ ------------------------- Rural Urban Rural Urban ------ ------- -------- -------- i) Educated/uneducated unemployed/under employed ii) Women iii) Others ------ ------- ------ ------ Total: ------ ------- ------ ------ d) Location(s) of Unit(s) 3.COST OF THE PROJECT: (Rs. in Lakhs) Registration, Total No. of Total S.No. Type of Cost per Cost of Insurance Cost Units cost Vehicle Vehicle/ Body Permit fee Per Chassis Fabrication & Interest etc Unit Note: Separate Proposal for each of type vehicle is to be furnished 1. MEANS OF FINANCE: S. No. Source Per Unit %age Total for.. Units 1. Promoter's Contribution 2. Subsidy 3. Loan -SCA 4. Term Loan - NSTFDC 5. Others, if any(specify) Total: NSTFDC FORMAT 3 5. IMPLEMENTTION SCHEDULE: i) Commencement (Month/year) ii) Completion (Month/Year) 6. Details of assumptions regarding operations ? No of Working Days in a year : ? KM operated per Day. : ? Rate per KM/Load : ? Cost of Fuel Per liter(latest rates applicable in the State) : ? Cost of Engine Oil per liter. : ? Qty & replacement norms (in Kms) of Tyres. : ? Consumption of Fuel per KM . : ? Cost of Mobil Oil per ltr. : ? Cost & Period for replacement. : ? Service Cost and periodicity. : FORMAT NO.3 (ANNEXURE I) COST OF OPERATIONS AND PROFITABILITY STATEMENT (PER UNIT) (Rs. in Lakhs) S.No. Particulars Ist year IInd year onwards A . Earnings B. Operating Costs i) Diesel/Petrol ii) Engine Oil/Mobil Oil iii) Replacement of Tyres iv) Insurance v) Repair & Maintenance vi) Interest vii) Depreciation viii) Other Expenses -------------- ----------------- Total operating Cost -------------- ----------------- C. Gross Profit(A-B) NEXT D. Cash Profit E. Profit Before Tax F. Tax G. Profit After Tax NEXT Format "A" NSTFDC DETAILS OF SELECTED APPLICANTS's FOR SEEKING DISBURSEMENT OF FUNDS NAME OF STATE CHANNELISING AGENCY (SCA)___________________________ NAME OF THE SCHEME & NSTFDC'S FILE No. _______________________________ NO.OF SANCTIONED UNITS S.No. Name of Person Father' s Name Postal Address Age Sex Rural : Urban Category * Annual Family Income (Rs.) Remarks CERTIFIED THAT ALL THE SELECTED PERSONS INCLUDED IN THE LIST ARE ELIGIBLE FOR ASSISTANCE AS PER ELIGIBILITY CRITERIA OF NSTFDC. SIGNATURE________________ ______ (AUTHORISED SIGNATORY) NAME & DESIGNATION OF OFFICIAL ______________ NOTE: I) Separate sheet to be used for each scheme *II) Please indicate Category Code as (1) for Educated Unemployed/under employed (2) for women (3) for others. NSTFDC ANNEXURE " B" FORMAT OF PROGRESS REPORT OF FUNDS UTILIZATION AS ON ________________ (REPORT TO BE SENT BY THE SCA TILL DATE OF FULL IMPLEMENTATION OF SCHEME) 1. NAME OF THE PROJECT/SCHEME : 2. NSTFDC's FILE NUMBER : 3. IMPLEMENTATION PERIOD AS PER SANCTION ACTUAL i) Date of Commencement : ii) Date of Completion : 4. BREAK UP OF NUMBER OF UNIT(S) AS PER SANCTION ACTUAL -------------------------- ------------------------ Rural Urban Total Rural Urban Total ------- ------- ------ ------- ------- ------ 5. STATUS OF BENEFICIARIES (No. of Beneficiaries-Owners of asset) AS PER SANCTION ACTUAL ------------------------- -------------------- - Rural Urban Rural Urban ------ ------- ------- ------- i) Educated /uneducated unemployed/under employed ii) Women iii) Others ----------- --------- ---------- --------- - Total ----------- --------- --------- --------- - Note: List of beneficiaries as per Annexure-I to be enclosed 6. COST OF PROJECT AND ACTUAL EXPENDITURE (Rs. In lakhs) ITEMS SANCTIONED ACTUAL --------- ------------------- ------------ i) No. of Units : ii) Cost per Unit : iii) Total Cost of Scheme/Project : 7. DETAILS OF SOURCES AND UTILISATIONOF FUNDS Sources Sanction Actual(Cumulative) -------------------------- ----------------------------- Per Total for... Per Total for .... Unit No.of Units Unit No.of Units ------------------------- ---------------------------- i) Promoter's Contribution ii) NSFDC's Share- iii) * Term Loan/ Bridge / : * Working Capital Loan : iv) SCA's Share v) Subsidy vi) Others(Specify) --------- ------------ ---------- ------------- Total ---------- ------------ ---------- ------------- 8 . DETAILS OF RECEIPT AND UTILISATION OF NSTFDC's SHARE RECEIPT FROM NSTFDC FUND RELEASED BY CHANNELISING * AGENCY TO SUPPLIERS /BENEFICIARIES Cheque/ Date Amount Cheque/ Date In favour Amount DD No. DD No. -------- ----------- ----------- --------- ------ ------------ --------- - *NOTE: Transfer of funds by Channelising Agency to its Branches/District Offices/Field Offices will not be treated as disbursement of funds . 9. Deviations from the Sanction : if any, alongwith reasons 10 Other relevant information : If any NSTFDC ANNEXURE-I LIST OF BENEFICIAIRES ? NAME OF CHANNELISING AGENCY ___________________________ ? NAME OF THE SCHEME _______________________________ ? NSTFDC's File No. Sl No. Name and Address of the Beneficiaries Age Sex Unit Cost NSTFDC 's Share Beneficiaries Category Code * Annual Family Income Remarks Rura l Urba n CERTIFIED THAT ALL THE BENEFICIARIES COVERED UNDER THE ABOVE LIST ARE ELIGIBLE FOR ASSISTANCE AS PER ELIGIBILITY CRITERIA OF NSTFDC. SIGNATURE______________________ (AUTHORISED SIGNATORY OF SCA) NAME & DESIGNATION OF OFFICIAL NOTE: Separate sheet to be used for each scheme.please indicate Category Code as (1) for Educated Unemployed/under employed (2) for women (3)for others. NSTFDC Annexure "C" FORMAT FOR FUNDS UTILISATION CERTIFICATE IN RESPECT OF WORKING CAPITAL ASSISTANCE 1. Name of the SCA/Agency : 2. Name of the Scheme : 3. NSTFDC's LOI No. & Date: 4. NSTFDC's share released: Date Amount i) ii) 5. Certified that: a) Funds have been utilised for the purpose/activities stated in the letter of sanction (LOI). b) An amount of Rs.__________ lakhs have been utilised within 60 days from the date of release of funds by NSTFDC for the implementation of the above said scheme. c) Total no. of ______________ Scheduled Tribes beneficiaries have been assisted under the scheme. d) All the beneficiaries covered under the scheme were eligible for assistance as per eligibility criteria of NSTFDC. Date: Signature (Authorised signatory of the Agency) Name: ______________________ Designation: __________________ (OFFICIAL STAMP)
