(APPL.FORM FEE Rs.100/-)

Maharashtra Rajay Itar Magas Vargiya Vitta Ani Vikas Mahamandal Limited.

MAHILA SAMRUDDHI YOJANA OF

( MICRO FINANCE SCHEME FOR WOMEN)

NATIONAL BACKWARD CLASSES FINANCE AND DEVLOPMENT

CORPORATION, New Delhi

LOAN APPLICATION FORM FOR

MAHILA SAMRUDDHI YOJANA

1.	Organisation Directory
(a)		Name of the Self Help Group	%	-----------------------------------------------------------------
(b)		Address	%	-----------------------------------------------------------------
(c)		State	%	-----------------------------------------------------------------
(d)		District	%	-----------------------------------------------------------------
(e)		Block	%	-----------------------------------------------------------------
(f)		Phone No. (with STD code)	%	-----------------------------------------------------------------
(g)		Fax No. (if any)	%	-----------------------------------------------------------------
(h)		Nearest Railway Station	%	-----------------------------------------------------------------
(i)		Registration No. of the Self Help Group	%	-----------------------------------------------------------------
(j)		Date of Registration	%	-----------------------------------------------------------------
(k)		Date of Renewal if any	%	-----------------------------------------------------------------
(l)		Area of operation	%	-----------------------------------------------------------------
(m)		Name of the Bank of Self Help Group	%	-----------------------------------------------------------------
(n)		Account No.	%	-----------------------------------------------------------------
(o)		Name and Designation of Chief Functionary	%	-----------------------------------------------------------------

2.	Details of socio-economic development programmes implemented by the Self Help Group during last 3 years
Year		Name of the Programme	Funded by	Amount received	Achievements
(1)		(2)	(3)	(4)	(5)

Note - Please enclose a copy of your annual reports of last three years.

For Office use only :

Code State Distt. Block Self Help Group

3. Experience of the Self Help Group in CREDIT Activity during last three years (Yearwise)

Years	Activities for which loan given	No. of SHGs	No. of borrowers	Amount of loan disbursed	Amount which was due for recovery i.e. Demand	Amount Actually Recovered	% of Recovery to Demand 7.6	Source of fund
(1)	(2)	(3)	(4)	(5)	(6)	(7)	(8)	(9)

4. Experience of the Organisation in thrift/savings and formation of SHGs. Please give details as below (position as on ……………………………)

(Amt. in Rs.)

Sr. No.	Name & Address of SHG	Date of formation	No. of members	Savings Mobilised	Loan given out of savings	Amount Recovered	Amount of loan outstanding
(1)	(2)	(3)	(4)	(5)	(6)	(7)	(8)
Total

5. Proposed lending Programme in the current year

Sr. No.	Category of loan	Name of Activities	No. of SHGs	No. of borrowers	Average amount of loan per beneficiary	Total Amount Required
(1)	(2)	(3)	(4)	(5)	(6)	(5x6)
	S.T.
	M.T.
	Total

6. Sources available with the Self Help Group

Sr.No.	Source	Balance at the beginning of year	Amount expected during the current year	Total Amount
(1)	(2)