APPLICATION CUM MONITORING FORM FOR GRANT-IN-AID TO VOLUNTARY ORGANISATIONS WORKING IN THE FIELD OF INTEGRATED PROGRAMME FOR OLDER PERSONS (for Ist installment and new cases) PART-A 1. Financial year for which Grant-in- aid is applied 2. Name of the Organisation 3. (a) Nature of the project(b) Date of commencement of the Project (c) Year of Commencement of Grant-in- aid from G.O.I for the Project (d) Whether the Project is recognised by the state government. 4. Date of Registration of the organization 5. Address of Registered Office 6.(a) Complete Address of Location / Locations wherever Programme / Project / Scheme is being implemented. (b) Nearest Railway Station/Bus stand 7. Whether building is8.(a) Is the building being utilized exclusively for this program ? OWNEDRENTEDONATEDON LEASENOYESSTD Code Tel. No Fax No.EmailSTD Code Tel. No (b) If no, provide details of usage 9.(a) Area of building (b) Number of rooms 10. Whether separate project-wise accounts have been maintained for grants sanctioned earlier ? 11. Whether Principle of joint operation of banks Accounts is being followed? 12. Details of bank accounts in which grant-in-aid released during previous financial year: Sl. No Grant-in- aid for financial year Sanction letter number and Date Recurring Amount Non- recurring Amount Bank A/c No. and date of deposit Name and address of Bank Person Operating the joint Account 13. Whether the statements of accounts submitted along with the application 14. The amount of support sought from the Ministry for recurring grant-in-aid (Rs. in lakhs) Cost Head Group (a) Recurring (b) Non-Recurring (c) Total 15. Whether List of Beneficiaries added as per Form-I NOYESAUDITEDUNAUDITED16. Whether List of Managing Committee added as per Form-II 17. Whether the List of Employees added as per Form-III Sq. mtrs PART BDetails regarding beneficiaries and program1. Nature and location of the Centre (separate form to be filled up for each Centre)2. No. of Older persons servedBetween 60-70 years Between 70-80 yearsAbove 80 years 3. Category / Background of the beneficiaries joining the centreNumber Percentage i) Low Income/cannot support themselves ii) High Income but nobody to look after iii) Widow/widower iv) No children to look after v) Have children but do not look after vi) Seriously ill and as such abandoned by family members vii) Quarrels in the family forced to join the centre viii) Joined the centre to do social service ix) Any other reason to join the centre 4. Availability of the following at centre Lighting Potable water Toilet facility 5. Details of Medical checkup and treatment of the Agedi) Annual expenditure on medicines Current year Previous year % ii) Whether there is a full time doctor or a part time doctor iii) If the doctor is part time, the number of visits per month iv) The fee paid to the part time doctor per visit v) Whether any nursing service is provided vi) The number of beneficiaries served for the whole year( in case of MMU) vii) The average number of visits by the mobile van per month (in case of MMU) viii) The number of visits the social worker paid to reach out to older persons for the whole year (in case of Non-Institutional Services) 6. Nutrition support (in case of OAH / DCC) No. of meals per day Breakfast /Evening Tea Average Daily exp. 7. Arrangements for recreationNewspapers Books Magazines Excursions Picnics Film show Religious congregation FULL TIMEPART TIM Rs. YESNO 8. What are the services for which the older persons join the centrei) For Nutritional support ii) For recreation iii) For health reason iv) For vocational training v) To provide social service through the centre vi) Any other factor (please specify) 9. Productive Activitya) Whether there are any facilities for productive activity for the beneficiaries b) If the answer to the above is yes give details of nature of such activitiesi) No. of persons involved in such activities ii) Income per year from such activities for10. Other Activities (other than productive activities)i) Whether any social service is undertaken by the centre a) By adopting specific areab) By linking with established institutions such as Orphanages, J.J. Institutes etc. Number Percentage Beneficiaries Rs.Centre Rs. YESNO % ii) What type of services are provided by the beneficiaries/centre to the community a. Teaching b. Planting Trees c. Vocational Training d. Cr che Services e. Any other Community Service f. Other (Please specify) 11. Are there any linkages with any other Organization / Institution If so, please specify the name of the organistion for each service i) Nutrition ii) Recreationiii) Health iv) Vocational Training v) Any other sector NOYES PART-C21. Organisations Funds FlowFOR THE ORGANISATION FOR THE PROJECT AS A WHOLE Particulars Previous Year (new Projects) Current Year Budgeted/ Actual actual Current Year Budgeted/ Actual I. Financial year II. Total INCOME , of which (i) funded by office-bearers donation from Private Sector (ii) funded by foreign contribution. (iii) funded by local bodies and public sector organization/State Govt. (iv) Grant from Central Govt.( indicate from each Ministry/ Deptt/ CAPART separately.) (v) Beneficiaries contribution/User Charges (vi) Miscellaneous income (vii) Any Other sources not mentioned above (specify) III Total Expenditure, of which (i) Recurring (ii) Non-recurring IV Detail of Expenditure on (i) Salaries & Wages(ii) Rental (a) Building (b) Furniture & fixture Year preceding the financial year of Grant- in-aid assistance indicated at SI. No.3(c) Part-A Year* Current Year Budgeted / Actual Previous No.3(c) Part-A Year preceding the financial year of Grant- in-aid assistance indicated at SI. No. 3(c) Part A Year preceding the financial year of Grant-in-aid assistance indic ated at SI.No. 3(c) Part A (c) Plant & Machinery(iii) Travelling, daily, etc. allowances iv) Other Administrative Cost: (v) Expenditure on beneficiaries a) In Cash vi) Expenditure on beneficiaries in Kind i) Food ii) Uniform / Clothing iii) Medicinesiv) Transport Facilityvi) Misc. (vii) Material costs incurred (For imparting Vocational Training etc. ) v) Recreation / Games (V). Cost per beneficiary
