Download Application Form for Short Stay Home

SCHEME OF SHORT STAY HOME FOR WOMEN AND GIRLS APPLICATION FORM Note: 1. The Application should be submitted in triplicate to the Child Development Programme Officer (CDPO) or District Women and Child Development Officer or District Social Welfare Officer of the Project area. 2. Applications either incomplete or without all enclosures will not be entertained. 3. Parts A & B should be completed by the applicant Organisation, Part C by the Inspecting Officer and Part D by the State Government. PART-A THE ORGANISATION 1. Name and full postal address of the : Head-office of the organisation. District: State: Pin Code: 2. Telephone No. with STD code. : 3. Fax No. : 4. Do the bye-laws of the NGO permit : it to receive Govt. grants and implement women's programme in the proposed project area? 5. Objectives of the Organisation : 6. Brief History of the Organisation (in : one paragraph) 7. Whether registered under Indian : Societies Registration Act (Act XXI of 1860) if so, give the number and date of registration. 8. Whether the organisation is of all : India character: If yes, give the address of its branches in different States including the State Branch which will run the Short Stay Home with Phone No. Fax No. etc. 9. Whether organisation is located in : its own/rented building. 10. Major activities of the organisation in the last 2 years: Name of the activity Coverage Expenditure Men Women Children 11. Summary of financial status of the organisation in the last year: (Rs. in Lakhs) 12. Details of grant received from Central Govt./State Govt. and other Govt. agencies in the last 2 years: (Rs. in lakhs) 13. Details of Foreign Contribution received during last 2 years: 14. Details of Office bearers of the Organisation: Year Income & Exp. Account Receipt & payment Account Surplus Deficit Sanction No. Order Date Amount Scheme Address of funding agency Country Organisation Purpose Amount Sl. No. Name & Address Male/ Female Age Post Qualifi­cation Profession Annual Income 15. Details of employees of the Organisation: Sl. No. Name & Address Male/ Female Age Part time/Full time Qualifi­cation Post Monthly Salary 16. Details of managing committee members of the organisation: Sl. No. Name & Address Male/ Female Age Occupation Profession Monthly Income PART-B THE PROPOSAL 1. Full address of the proposed : location of the Short Stay Home. District: Block: Pin Code: Telephone No. with STD Code: 2. Whether the location is a District : Head Quarter, Block Head Qrs. Tehsil Hqrs. or village. 3. Accommodation of available for the Short Stay Home: 4. Is it rent-free accommodation: 5. Classification of proposed beneficiaries: 6. No. of Family Counselling Centres in the District; 7. Is your NGO running any Family Counselling Centre: 8. No. of Destitute Homes run by the State Govt. in Your District: No. of rooms Total Area (Sq.ft. Room Kitchen Toilet Store Varandah Open space Total Type of Problem No. of Women (Proposed Beneficiaries) In moral danger Victims of Rape Cruelty by family members Deserted by Husband Family Discord Others (please specify) Total Date. Signature of Secretary/ President LIST OF DOCUMENTS TO BE ENCLOSED: 1. Registration Certificate 2. Prospectus or a note giving aims and objects of the organisation. 3. Constitution of the organisation/ Byelaws and Memorandum of Association. 4. Constitution of the Board or Management with brief particulars of each member. 5. Annual report for the last 2 years. 6. Audited accounts for the last 2 years. 7. Details of women/girls proposed to accommodated in the Short Stay Home including their name and address, age and case history in not less than one paragraph for each person. 8. A one-page note on "How you will run a Short Stay Home". PART-C PROFORMA FOR PRE-SANCTION APPRAISAL REPORT (Enclosed Guidelines may be referred to very carefully before Pre-sanction Appraisal) 1. Name, Designation and full Address of the Inspecting Officer : 2. Date and time of visit : 3. Name and full postal address of NGO. : 4. Is a name beard prominently displayed by the NGO. : 5. Have you inspected the original Registration Certificate of the NGO and is it satisfactory? : 6. Are any managing Committee Members related to each other? If yes, names of members and their : relationship. 7. Are the office bearers of the NGO : associated with any other NGO> If yes, names of other NGO(s). 8. Does the NGO have staff as mentioned : in the application from? If not, please indicate the shortfall. 9. Are copies of the audited accounts submitted by the NGO true copies of the Original? : 10. What is the present bank balance of the NGO. : 11. Whether credit entries are available in the passbook for various income of the NGO mentioned in the audited account? If yes, what amount have been credited in the passbook for the following income? (a) (b) © (d) (e) (f) Donations. Members Contribution: Sale of goods: Income from activities: Grants: Loans from members: Year Year 12. Do you have reasons to believe that the entries in the Audited Accounts are : genuine? Please elaborate 13. Name the activity taken up by the NGO : for which evidence was available: 14. Is there any ongoing activity of the : NGO? If yes, please visit some of them and report on performance. 15. Name the activities included in the : audited accounts and annual report for which no evidence was available. 16. Name the assets included in the : Balance Sheet but not available for physical verification. 17. Are the local people aware of the NGO : and its activities? 18. What is the opinion of local people : about the NGO? 19. Have you come across any instance of : misutilisation of funds or complaint involving the NGO? If yes, please give reasons. 20. In your opinion, is the NGO capable of : implementing the project applied for? Please give reasons. 21. In your opinion, is there genuine need : for the project in the proposed project area? Please give reasons. 22. Has the NGO furnished details of : beneficiaries proposed to be covered? If yes, please visit a few of them and furnish the following information. 23. Any other information about the NGO : Name of the Beneficiary Whether below poverty line Whether genuinely in need of assistance under the project. I have read the guidelines for pre-sanction appraisal. This report does not contain any mis-representation of facts. GUIDELINES FOR CDPOS FOR PRE-SANCTION APPRAISAL Vide Department of Women and Child Development letter No.12-25/98-MSY dated 22.07.1999, CDPOs have been designated as Nodal Officers for all schemes of Department of Women & Child Development. NGOs are required to submit all proposals for grant-in-aid for Women and Child Development Schemes to CDPOs. In the absence of CDPO, the Women & Child Development Officer or Social Welfare Officer for the project area may inspect the project and submit report. On receipt of proposals for grant-in-aid from NGOs, the CDPO / Inspecting Officer is required to take the following steps: 1. Check whether 3 copies of the proposal have been submitted. 2. Check whether the proforma prescribed under the relevant scheme has been used by the NGO. 3. Check whether all columns in the application form have been filled. 4. Check whether all the annexure to be attached with the application form have been actually attached. Ensure that audited accounts and Annual report are for the last 2 years. 5. Visit the NGO with prior intimation and fill up the inspection proforma. While sending intimation to the NGO about visit, ask the NGO to keep all documents such as registers, audited accounts, receipt books, cash books, passbook, documents not attached with application form etc. ready. 6. During the visit, obtain missing information / documents etc. as the case may be so that the application is complete. 7. While filling up the proforma, please do not use statements such as "As given in the Audited Accounts." "As given in the Annual Report" etc. The factual position may be indicated. 8. Send one copy of the inspection report and the complete application to Desk Officer, Department of Women & Child Development, Govt. of India, Jeevandeep Building, Parliament Street, New Delhi. The second copy of proposal and inspection report should be sent to the State Government through proper channel. The third copy may be retained by the inspecting officer for office record. This should be done within 30 days of receipt of application from NGO. Please Note: 1. The proposal and inspection report should be sent to Department of W&CD within 30 days from date of receipt of application. 2. All columns in the Application Form and inspection report should be filled legibly and all enclosures as prescribed in the application form should be attached. 3. The report is open for random check by the Govt. or its agencies. Adequate care may be taken to avoid mis-representation of facts. PART-D RECOMMENDATION BY STATE GOVERNMENT (To be sent within 90 days from date of appraisal report by CDPO, if no reply is received within the time frame, it will be presumed that the State Government supports the proposal) 1. Name and full address of the : Organisation 2. Name of the Scheme for which : application is made 3. Name & designation of the Officer : who inspected the Organisation. 4. Do you agree with the report of the : Inspecting Officer and if not, reasons thereof. 5. Does the Organisation fulfill all : eligibility criteria for grants under the scheme? 6. Will the State Government recover : sanctioned grants in the event of misutilisation of funds? 7. Is the Organisation capable of : implementing the project applied for? 8. Is there any complaint of mis-: utilisation of funds or other irregularities by the organisation. 9. What is the justification for the : project applied for? 10. Is the proposal recommended for : sanction of grants? (Signature) Name: