Scheme for Shelter Homes for Women
Application form for submitting proposal for sanction of grant under the Scheme for Shelter Homes for Women
Part – I
(To be completed by the Applicant)
1. Name of the Institution / Organization
2. Objectives of the Institution / Organization
3. Brief history of the Institution / Organization and its objectives and activities
4. Whether registered under Indian Societies Registration Act (Act XXI of 1860)
5. Whether located in its own / rented building
6. Whether the project is likely to be assisted by some other official or non-official source (if so give details thereof)
7. Justification for the project including its important features which entitle it to Assistance under the
Scheme.
8. Total estimated expenditure on the Shelter Home for Women for one year
(i) Non-recurring
(ii) Recurring
(iii)Period
for which recurring assistance is required
Rs.
Rs.
9. Amount of grant requested Estimated expenditure
(i) Non-recurring
(ii) Recurring
(iii)
Period for which recurring assistance is required
Rs.
Rs.
10. Is accommodation available for running the Shelter Home for women or temporary shelter is proposed to be improvised?
Proposed location of Shelter Home for Women with full address
11. Whether the institution is in a position to meet excess expenditure? If so, indicate the sources.
12. List of papers/statements to be attached
(i) Prospectus or a note giving aim s and objects of the Institution/ Organization.
(ii) Constitution of the Institution/ Organization
(iii) Constitution of the Board Management with brief particulars of each members.
(iv) Latest available annual report Audited
accounts for the last two years along with a copy of the certified balance sheet for the
previous year
(v) A statement giving details (year, purpose, amount etc.) of assistance/grant received during
the last two years from the Central/State Government institutions/ N.G.O./ foreign assistance including requests made thereof to any of those or any other organization for the project under consideration.
(vi) A statement giving item - wise and year-wise details of estimated recurring and nonrecurring
expenditure on the proposed project
13. List of additional papers if any.
14. Additional information, if any
15. Does the Institution/Organization work
for profit to any individual or body of individual?
Signature of Secretary / President

Part – II
(To be filled by the Social Welfare Officer in the Directorate of W om en and Child Development)
Recommendations
The application from ---------------------------------------------------------------------------------
(institution/organization) is recommended with following comments.
I. That the undersigned has visited the institution/organization and a copy of the report is
attached/has not visited the institution/organization.
II. That the institution/organization is recognized and/or registered (under Indian Societies Registration Act, 1860) and the registration is valid.
III. That the application has been examined and that it is found to be covered under the scheme.
IV. That the scheme for which the application is being recommended is absolutely essential for women and girls who have no social or family support.
V. That the work of the institution/organization has been reported (whether such reporting is necessary) as satisfactory during the last two years.
VI. That the institution/organization is not run for profit to any individual or a body of individuals.
VII. That assistance has/has not been given by the state Govt.
Signature of Social Welfare Officer.
(Office Stamp)
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