ANNEXURE-A

APPLICATION CUM APPRAISAL FORM FOR SGSY LOAN

FIRST LOAN/SUPPLEMENTARY LOAN SGSY Identification No:

(If given)

The Manager,

(Name of the Bank)

(Place)

Dear Sir,

I/We, the members of the same family, hereby apply for a loan of Rs………..(Rupees………………………………………………………………………….) for the following purposes and furnish below the necessary particulars:

Term Loan

(Indicate the purpose) Amount Rs.

(a)

(b)

©

Total Rs._________

GENERAL INFORMATION

(a) name of the applicant(s) Age Father/Husbands Name

(i)

(ii)

(iii)

(b) Resident Address

(Village/PO/Taluka/District)

© (I) Name of the Head of the family:-

(ii)No. of members of the family:-

1)Adults

2)Minors

(iii) present Annual income of the family: Rs

.(d)Whether the applicant belongs to SC/ST (please specify)

(e)Whether the applicant is a small farmer/Marginal farmer/ agricultural labourer/ Rural artisans/others(Please specify)

(f)Whether the applicant or any of his family members has availed of any loan under IRDP/SGSY earlier. If so furnish details.

Name of the Type of Amont of Loan Amount Beneficiary investment subsidy rece’d amount outstanding Disbursed

1) (2) (3) (4) (5)

i)

(g)Details of land under cultivation:-Owner land

Village Survey No: Total Acre Land revenue Dry Wet Total

(1) (2) (3) (4) (5) (6)

(ii)Land on lease/Rent etc:-

Village Survey No: Nature of right Total Dry Wet Total

(1) (2) (3) (4) (5) (6)

(h)Particulars of equipment owned:-

(As on the date of the application)

Equipment (Particulars/description)

(i)Plough cattle

(ii)Dairy cattle

(iii)Oil engines/pumpsets/Electric motor etc.

(iv)Others(please specify)

Particulars of the existing liabilities if any of the household:-
(As on the date of the application)

(a)Date of receipt of application from DRDA/BDO:-

(b)Whether the proposed activity /activities is are technically feasible:-

© Whether backward and forward linkages are available:

(d)Financial viability:-

Type of Investment Total cost of Expected income from the new investment

Scheme* Gross income Expdt . on Maint. Net

(Rs) etc of the asset(Rs) Income

(1) (2) (3) (4) (5)

*

Working capital component, where applicable to be mentioned separately.

(e) Expected Annual Expenses of the family: Rs.

(f)Subsidy amount available for the investment.

(i)

(ii)

(g)Loan amount(including working capital, wherever necessary) recommended:

Type of investment Amount in Rs.

(h) Repayment Schedule recommended:-

To be paid in --------------monthly/quarterly/half yearly/ yearly installments commencing from------------and Rs.-------------per installments with balance payment of Rs------------as the last installment.

(i)Rate of Interest:-

(j)Security

1. Primary
2. Additional if any:-

(k) Others terms & conditions:-

(i)Insurance (ii)

(l)Whether RBI/NABARD norms relating to the rate of interest, unit cost, gestation period, repayment period etc have been fully complied with:-

Signature of processing official

(m)Sanctioned as per the above terms and conditions

Or

Rejected/Reduced amount sanctioned

(Reasons thereof are to be recorded)

Signature of the Branch Manager

Date.

Primary Agricultural Credit Society/LDB/Government loan(Taccavi)Commercial Bank/RRB/Urban Bank/Others(Pl. specify)

I/We hereby declare that the particulars given above are true and correct to the best of my/out knowledge and belief. I/We also agreed to the summary procedure for recovery prescribed under the State Recovery act.

I nominate--------------------------, relationship-----age------years as my nominee to receive the claim amount under the Group Life Insurance scheme for SGSY beneficiaries in the event of my death.

Signature(s) of the applicant(s)

Date:

Recommendations of BDO/DRDA

I certify that the above household is identified as SF/MF/AL/Non-AL/RL/under the SGSY identification No:------The investment(s) is/are included in the application of the applicant (s) is /are recommended for granting subsidy/loan. He is eligible as per Govt. guidelines for grant of 2^nd dose of credit. The applicant(s) is/are not defaulter(s) to any of the cooperative Credit Institutions.

Signature

Name of Designation of the official

Date:-

UT: A.& N ISLAND CD BLOCK:

1. Name of the applicant:
2. Name of the Head of the family:
3. Name of the father/husband:
4. Resident of village:
5. Occupation:
6. Source of Income(a) Farm income (b) Non-Farm Income:-
7. Annual Income from all sources:-
8. S.No: in the BPL List:-
9. Details of family members:-

S.No Name Relationship Sex Age Qualification Remarks

With the HOF

10. Details of land holding:-

S.No: Total location of plot

11. System/condition of present house:-
12. Whether sanitary latrine available or not:-
13. Remarks if any

Signature of Surveyor/VLW Signature of the applicant.

Report of the Tehsildar about land holding:-

Patwari Tehsildar.

Recommendation of the Block Development officer:

From,

To,

The Deputy Commissioner,

Andaman District,

Port Blair.

Sub: Construction of New Pour Flush Latrine under Rural Sanitation Programme (PFL under MNP) :-

Sir,

I am to inform you that I am the owner of the houses situated in Survey No:------- village -----------Tehsil. I am interested in construction of a pour Flush latrine under MNP programmes in the aforesaid house as per design and drawing and on terms and conditions specified by the directorate. The number of the persons residing in my household as per month.

It is requested that sanction of loan and subsidy may kindly be accorded as per approval schemes.

Yours faithfully,

Dated : Signature.

Name :

F/H/Name:

R/o:

Certificate/Undertaking

Shri----------------is my son/daughter/tenant /Purchaser who is residing on my residing on my recorded landed property bearing Survey No:------------situated at-------------- under on the land bearing Survey No:-------by my son/ daughter/tenant/purchaser.

Signatures of owner

Report of the Tehsildar Name:

(Tehsildar)

Report of V.L.W.

1. About residential building existing:-
2. Present existing system of latrine:-

Extension officer VLW

Circle circle

Recommendation of the Block Development officer:-

Block Development officer.

Order of the Deputy Commissioner(A/N)

Deputy Commissioner, Andamans,/ Nicobars..