APPLICATION FOR BENFIT OF FINANCIAL INCENTIVES TO MOTHERS WHO DELIVERS A GIRL CHILD (MAMTA)”
From : -
_______________________,
________________________.
Date:-___________________
To,
The Child Development Project Officer,
ICDS ____________________,
__________ – Goa.
Sub:- APPLICATION FORM FOR FINANCIAL INCENTIVES TO MOTHERS WHO DELIVERS A GIRL CHILD
Madam ,
I, the undersigned is applying for the “ Financial Incentives to m others who deliver a girl child (MAM TA)” and enclosing herewith all necessary attested documents as required.
Kindly do the needful.
Thanking you,
Yours faithfully,
( )
Encl: The application shall be enclosed with the following documents.
1. Annexure -I
2. Certified copy of Ration Card.
3. Certified copy of Birth Report/Certificate from registered institution in Goa.
4. The m other should be resident of Goa for last 3 years or married to a resident of Goa (Attested documents to that effect to be submitted).
1. Pre-receipt in duplicate.
2. M other should apply within 45 days of delivery.

ANNEXURE -1
Application form of Scheme
Financial incentives to mothers who deliver a girl child (MAMTA)
1. Nam e of the M other ( in full) :_______________________________
2. Age of the M other : ______________________________
3. Residential Address :______________________________
Village : ______________________________
Constituency : ______________________________
Taluka : ____________________________
District : _____________________________
State :_____________________________
4. Contact Num ber : _____________________________
5. Bank/Post Office Account No.: ______________________________
6. Caste (W hether SC/ST/OBC/
other) :_____________________________
7. Religion : ______________________________
8. Nam e of the Doctor :______________________________
9. Nam e of the registered
m edical Institution where
delivered : _____________________________
10. Date of Delivery : _____________________________
11.Nam e of the Child if any :______________________________
12. W eight of the Girl Child :_______________________________
13.Nam e of the Anganwadi
Centre, if any. : ______________________________
14.Fam ily Incom e : ______________________________
15. Details of the other
children
: Nam e Sex Date
of
Birth
1.
2.
3.
Declaration
I, Shri/Sm t___________________applicant herein below declare that I have
not applied for the benefits other than the application for the above child
under the schem e M am ta and authority are free to recover the m oney with
interest, if found for the under in case excess claim .
_________________________
( Nam e of the m other with date and signature )
PRE-RECEIPT
Dated:-
Received from the Child Development Project Officer,
I.C.D.S,__________________, Directorate of Women & Child Development, Panaji –
Goa an am ount of Rs. 5,000/- ( Rupees five thousand only ) towards “ Financial
incentives to m others who deliver a girl child” (M AM TA).
( )
Nam e and Signature of the receiver
with Revenue Stam p.
---------
PRE-RECEIPT
Dated:-
Received from the Child Developm ent Project Officer,
I.C.D.S,__________________, Directorate of W om en & Child Developm ent, Panaji –
Goa an am ount of Rs. 5,000/- ( Rupees five thousand only ) towards “ Financial
incentives to m others who deliver a girl child” (M AM TA).
( )
Nam e and Signature of the receiver
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