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 Civil Surgeon / Medical Officer Incharge ___________________________Municipality. Subject:- Balika Samridhi Yojna - 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 applicant (Mother) _____________________________________________ 2. Name of housband ____________________________________________________ son of ______________________________________________________________ 3. Full address : House number ____________ Street ____________________ Locality ________________________ Village ______________________________ Block/ Tehsil/ Taluk __________________________ District __________________ 4. Date of birth of applicant (Mother) _______________________________________ 5. Date of birth of newborn girl child _______________________________________ 6. Place 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. Authorisation : I hereby authorize the implementing agency for BSY to open an interestbearing account in the joint name of my new born 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 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 girls child on her attaining 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 : 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 towards the Bhagyashree Balika Kalyan Bima Yojna 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: ______________ Verified and reported that: 1. Smt. _____________________wife of Shri_________________________ of House Number_________ Street ________________Town/ City _____________________ has given birth to a girl child on (date) ________________ as per Birth Register/ Birth Certificate. 2. The girl child has been given the following immunization: BCG/ Measles/ DPT/ Polio. 3. The family of Smt._____________ wife of Shri_________________ of Town/ City_____________ has been shown at serial number __________________ in the list of families below the poverty line under (name of BPL survey__________________. OR, The family is a BPL family as per the criteria mentioned in BSY guidelines. 4. The total number of beneficiaries in the family under BSY including the newborn girl child above is _______________________. Urban Anganwadi Worker/ Multi Purpose Health Worker (Female)/ Health Supervisor (Female)/ Revenue Officer/ Municipal Officer Place __________________ Date __________________ Signature of Secretary/ Executive Officer Municipality Place __________________ Date __________________ This is to sanction Rs.500/- as post-birth benefit in favour of (new born girl child)________________ daughter of Smt. ________________________________ wife of Shri __________________________ of Town/ City _____________________ under BSY. The sanction has been approved/ vill be retified by a resolution of the Municipality. This sanction order will be notified on the notice board of the Municipality . Signature Secretary/ Executive Officer Municipality Place : _________ Date : _________ In pursuance of the above sanction, an interest-bearing account has been opened in the joint name of the newborn girl child above and (name and designation of the officer of the implementing agency)_____________________________________and the passbook for the same has been handed over to the applicant (mother of the newborn girl child) as per the details below:- 1. Name of bank or post office where account opened ________________________. 2. Date of opening of account ___________________________________________. 3. Deposit scheme under which account opened and number of account opened _____________________________. 4. Amount deposited : Rs.____________ (Rupees _______________________only) 5. Passbook number __________________________________________________. 6. Amount paid in cash to applicant (mother) as reimbursement of insurance premium as per the application : Rs.________________ (Rupees _____________________________ only) Name designation & Signature of officer of implementing authority Place : _________ Date : _________ Received the following from be implementing agency:- 1. Cash amount of Rs.____________ (Rupees__________________________ only) as reimbursement of insurance premium as per the application. 2. Passbook number __________ for Rs._________ (Rupees _________________ only) Signature of applicant (mother) Place : _________ Date : _________ Note:- Model forms relating to BSY benefit of annual scholarships when the girl child starts attending school will be devised and circulated to State Governments/ Union Territory Administrations. Urban Area RECEIPT Received application for obtaining the post-birth benefit of Rs. 500/- in favour of (name of newborn girl child) ________________________ from Smt._____________________ wife of Shri _____________________ of Town/ City___________________________ on _________________. Urban Anganwadi Worker/ Multi Purpose Health Worker (Female)/ Health Supervisor (Female)/ Revenue Officer/ Municipal Officer Place __________________ Date __________________ Note : 1. Please approach the Ward Councillor/ Chairperson, Municipality if the time taken in providing the benefit of Rs.500/- exceeds 90 days from the date of application. 2. Please enclose a copy of this receipt alongwith with the complaint regarding delay.
