Department Name : Department of Minority Affairs

Service Name : Micro finance NGO Loan For minority

Service Code : 2594

APPLICATION BY NGO's FOR AVAILING MICRO-CREDIT FORM NMDFC/SFCs

Aadhaar (UID or EID Number)……………………………………. Bhamashah ID………………………………………………………

Applicant Information

1.Title...... 2. Name of Owner...... 3. Father / Husband Name......

4.Gender...... 5. Caste Category...... 6. Mobile Number......

7. BPL Card Number......

Organization Directory

1. Name of Organization………………………………………… 2. Phone no. (With STD Code)……………………………………………..

3. Fax No. (If any)…………………………………………………… 4. Nearest Railway Station……………………………………………………

Current Address

1. Address In English...... 2. Address in Hindi......

3. Country…………………………………………. 4. State…………………………………………. 5. Division…………………………………………..

6. District……………………………………………… 7. Tehsil ……………………………………….. 8. Municipality......

9. Ward………………………………………… 10. Panchayat Samity……………………………………………………..11 Gram Panchayat……………………………………

12. Village……………………………………………… 13. Pin Code…………………………………………………

Permanent Address

1. Address In English...... 2. Address in Hindi......

3. Country…………………………………………. 4. State…………………………..…………………… 5. Division……………………………………………….…………..

6. District……………………………………………… 7. Tehsil……………………………………….. 8. Municipality......

9. Ward………………………………………… 10. Panchayat Samity……………………………………………………..11 Gram Panchayat…………………………………….

12. Village……………………………………………… 13. Pin Code…………………………………………………

Area of Operation

1. As per MOA……………………………………………. 2. For Implementation of this programme……………………………………………………….

3. Name of Bank of Organization………………………………………………………….

4. Account No………………………………………………………………………………………..…

5. Name and Designation of Chief Functionary…………………………………………………………………………..

Resources available with the organization

Sl. No. / Source / Balance at the beginning of the year / Amount expected during the current year / Total amount
1. / Own sources
2. / Saving of SHGs/members
3. / Recovery sources such as grants/donations etc.
4. / Borrowings (Other than this application NMDFC)
5. / Total

Financial assistance required from NMDFC

Amount / Name of Activist / No. of SHGs / No. of borrowers / Average amount of loan per beneficiary / Amount required from NMDFC
(i)As per para-5 / Own sources
(ii)minus as per para 6 / Saving of SHGs/members
(iii)Balance required from NMDFC / Recovery sources such as grants/donations etc.

Financial position of the organization as per balance Sheet (As on....)

1. Fixed Assets...... 2. Current Assets………………………………………………………..

3. Borrowing (Details of borrowing if any may be given in Performa)……………………………………………………………………………

4. Other Liabilities……………………………………………………………………………..

Bank Detail

1. IFSC Code……………………………………………………………………………….. 2. Name of Bank…………………………………………………………………

3. Name of Bank Branch……………………………………………………………. 4. Account Number……………………………………………………………………….

Declaration: The information provided by me is true to the best of my knowledge

Signature of Applicant