BALIKA SAMRIDDHI YOJANA (BSY) ( No document other than the application form is necessary for obtaining the post-birth benefit of Rs.500/-) APPLICATION FORM FOR OBTAINING THE POST-BIRTH BENEFIT OF RS.500/- (FOR URBAN AREAS) To Municipal Officer, ............, Municipality. Subject: Balika Samriddhi Yojana - 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 husband ................... son of ........................................................................................... 3. Full address: House number ........ Street.......... Locality ........... Town/City............ Block/Tehsil/Taluk........... District .......... 4. Date of birth of applicant ................. (mother) 5. Date of birth of newborn girl child ............... Place of birth of newborn girl child ................ Name of newborn girl child .................. Number of girl children in the family already benefitted under BSY excluding the newborn girl child ......... 6. Whether belonging to i) SC.... ii) ST ......... ii) OBC .... iv) Others ........ 7. 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 newborn 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 girl 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 toward the Bhagyashree Balika Kalyan Bima Yojana 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..... 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 Heath Worker (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. 1. Please enclose a copy of this receipt along with the complaint regarding delay. 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 the 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 (newborn girl child) ......... daughter of Smt. .......... wife of Shri ............. of Town/City . ....... under BSY. The sanction has been approved/will be ratified 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 and signature of officer of implementing agency Place ......... Date ........ RECEIPT Received the following from the 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 ........ 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. BALIKA SAMRIDDHI YOJANA (BSY) APPLICATION FORM FOR OBTAINING THE POST-BIRTH BENEFIT OF RS.500/- (FOR RURAL AREAS) ( No document other than the application form is necessary for obtaining the post-birth benefit of Rs.500/-) To Chairperson/Secretary/Executive Officer, Gram Panchayat. Subject: Balika Samriddhi Yojana - 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 husband ..................... 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 benefitted 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 newborn 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 girl 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 toward the Bhagyashree Balika Kalyan Bima Yojana 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..... 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 village ........... on ......... Anganwadi Worker/ANM*/ Village Revenue Officer Place ......... Date ........ Note 1 Please approach the Panchayat Member/ Chairperson, Gram Panchayat if the time taken in providing the benefit of Rs.500/- exceeds 90 days from the date of application. 1. Please enclose a copy of this receipt along with the complaint regarding delay. * Auxiliary Nurse/Midwife Verification and Report Verified and reported that:- 1. Smt. .............. wife of Shri ........ of House Number ............. Street ............... Village ........ has given birth to a girl child on ( date ) ...... as per the 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 Village .......... has been shown at serial number .....in the list of families below the poverty line under Swarnajayanti Gram Swarozgar Yojana (previously known as IRDP). 4. The total number of beneficiaries in the family under BSY including the newborn girl child above is ......... Anganwadi Worker/ANM*/ Village Revenue Officer Place ......... Date ........ Signature of Secretary/ Executive Officer Gram Panchayat Place ......... Date ........ *Auxiliary Nurse/Midwife SANCTION This is to sanction Rs.500/- as post-birth benefit in favour of (newborn girl child) ......... daughter of Smt. ..........wife of Shri ............... of Village ....... under BSY. The sanction has been approved/will be ratified by a resolution of the Gram Panchayat. This sanction order will be notified on the notice board of the Gram Panchayat and will be announced in the Gram Sabha. Signature Secretary/Executive Officer Gram Panchayat 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) 1. Passbook number ...... 2. Amount paid in cash to applicant (mother) as reimbursement of insurance premium as per the application: Rs. /- (Rupees .....only). Name, designation and signature of officer of implementing agency Place ......... Date ........ RECEIPT Received the following from the 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 ........ 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.
