Annexure-IApplication for Central Scheme of Assistance to Disabled Persons for Purchase/Fitting of Aids / Appliances To The Secretary to the Government of India, Ministry of Social Justice & Empowerment, Shastri Bhawan, New Delhi Subject: Assistance under the Central Scheme of Assistance to Disabled Persons for Purchase / Fitting of Aids / Appliances. I submit herewith an application for a grant for the year under the Scheme of Assistance to Disabled persons for Purchase / Fitting of Aids / Appliances. I certify that I have read the rules and regulations of the Scheme and I undertake to abide by them, on behalf of the Management. I further agree to the following conditions: (a) All assets acquired wholly or substantially out of the Central grant shall not be encumbered or disposed off or utilized for purpose other than those for which the grant is given. Should the Institution / Organisation cease to exist at any time, such properties shall revert to the Government of India. (b) The accounts of the project shall be properly and separately maintained. They shall always be open to check by an officer deputed by the Govt. of India or the State Government. They shall also be open to a test check by the Comptroller and Auditor General of India at his discretion. (c) If the State or the Central Govt. have reasons to believe that the grant is not being utilized for approved purpose, the Govt. of India may stop payment of further Installments and recover earlier grants in such a manner as they may decide. (d) The Institution shall exercise reasonable economy in the implementation of the scheme. (e) The Organisation will obtain an undertaking from the beneficiaries as required under the scheme, before Fitting / Giving of Aids / Appliances. Yours faithfully, (Office Stamp) Date Designation FromSignature Ministry of Social Justice & Empowerment 2. (i) Name of the Act under which Registered (ii) Registration No. and date of Registration Any other Organisation / Institute/ / Body, if applicable, give details 3. Registration under Foreign Contribution Act 4. Memorandum of Association and Bye-Laws. (Please attach a photocopy) 5. Name & Address of the Members of the Board of Management / Governing body Annexure-II YESNO 1. Organization Name Address (Office) (Project) Phone (Office) (Project)Fax (Office) Telex (Office)E-mail (Office) (Project) Grams (Office) (Project Name of the Scheme& Date 7. Details of the Project for which the Grant-in-aid is being applied. 8. Grant-in-aid applied for in the current year. 9. Details of beneficiaries. (a) Number of disabled benefited from previous year's grant. (b) Proposed number of disabled expected to be covered during current financial year. 10. Details of the staff available 11. Details of GIA received under other Schemes of State Govt Central Govt Other sourcesProgramme / Project run by the NGO (other than the one applied for) Grant-in-aid Received Amount Service Agency Total Expenditure on the Projects Location of the Projects 12. List of Additional papers (if any given) I have read the Scheme and fulfill the requirement and conditions of the Scheme. I undertake to abide by all the conditions of the Scheme. (Seal) Note: Wherever not applicable, specially in case of new Organisation, please write-N.A. 6. List of Documents to be attached. (a) A copy of the Annual Report for the previous year which should contain the Balance Sheet (including Receipt and Payment Account), Income and Expenditure Account. Name Address DateSignature Click Attach Button to Attach the Soft Copy MINISTRY OF SOCIAL JUSTICE & EMPOWERMENT 1. APPLICATION FORM FOR THE IIND INSTALLMENT Total A. Applied in the current year 1. Organization Name Address (Office) (Project) Phone (Office) (Project)Fax (Office) Telex (Office)E-mail (Office) (Project) Grams (Office) (Project2. Grant-in-aid (in Rs.) Name of the Scheme B. Received as Ist Installment C. Applied for IInd Instalment (Seal) 3. The applicant organisation should enclose following papers: i) Annual Report of the previous year. ii) Audited Statement of accounts of previous year (Receipts and Payments Statement, Income & Expenditure Statement) and Balance Sheet. iii) Audited utilization certificate with itemwise expenditure as per the sanctioned items of Grant. iv) Details of staff available. v) Details of beneficiaries as per Annexure IV vi) Assets acquired wholly or substantially out of government Grants under GFR 19. vii) Any other information considered necessary by the organisation or as asked for: List of AttachmentsDate AddressName Signature
