BALIKA SAMRIDHI YOJANA (BSY) Application Form for Obtaining The Post- Birth Benefit of Rs.500/(FOR URBAN AREAS) (No document other than the application form is necessary for obtaining the post-birth benefit of Rs. 500/-) To Municipal Councilor, ............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 the 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 ..................... 6) Placed of birth of newborn girl child ................... 7) Name of newborn girl child ...................... 8) Number of girl children in the family already benefited 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. Authorization 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 -1 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 attending 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. 1. 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 ......... -2
