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Form 1-C (To Claim 3rd Instalment Under PMMVY)

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vasanth8555
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67 views4 pages

Form 1-C (To Claim 3rd Instalment Under PMMVY)

Uploaded by

vasanth8555
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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(FILLED UP FORM SHOULD BE SUBMITTED TO AUTHORISED PERSONS ONLY)

Form 1-C

APPLICATION FORM FOR CLAIM OF THIRD INSTALLMENT UNDER PMMVY

Mandatory fields*

1. Name of beneficiary*: ___________________

2. Aadhaar/Identity number of beneficiary*:____________________

Identity Proof provided (tick one, as appropriate):

a) Bank or Post Office photo passbook


b) Voter ID Card
c) Ration Card
d) Kishan Photo Passbook
e) Passport
f) Driving License
g) PAN Card
h) MGNREGS Job Card
i) Her husband’s Employee Photo Identity Card issued by the Government or any Public Sector Undertaking;
j) Any other Photo Identity Card issued by State Government or Union Territory Administrations;
k) Certificate of identity with photograph issued by a Gazetted Officer on official letterhead;
l) Health Cardissued by Primary Health Centre (PHC) or Government Hospital;
m) Any other document specified by the State Government or Union Territory Administration

Note: Alternate ID for claiming this instalment will beaccepted only in Jammu and Kashmir, Assam and
Meghalaya.

3. Date of delivery*: ____________________

4. Did the delivery take place in a Government approved facility?* : Yes No

a. If yes, Name of Government approved facility_______________________________________

5. Tick yes, if already registered under the scheme: Yes No (If no, then fill Form 1-A)(If yes, enclose
copy of Acknowledgement Slip)*

6. Gender of Child/ Children*:

a. □Male □Female (Please tick)

In case of multiple births, fill the following:

b. □Male □Female (Please tick) (in case of twins)

c. □Male □Female (Please tick) (in case of triplets)


d. □Male □Female (Please tick) (in case of quadruplets)

7. First cycle of Vaccinations given*:

a. BCG or equivalent/substitute: Yes No

b. OPV or equivalent/substitute: Yes No

c. DPT or equivalent/substitute: Yes No

d. Hepatitis- B or equivalent/substitute: Yes No

8. Date of completion of first cycle of vaccinations*: ________________

9. Tick ‘Yes’ if beneficiary reports case of any previous still births: Yes No

10. Enclose copies of*:

a. Child Birth Certificate

b. MCP card with immunization details

11. Health ID of beneficiary: _________________________________________

12. Details to be filled Anganwadi Worker / ASHA /ANM

Anganwadi Centre Name/Approved Health Facility Name: __________________________

Anganwadi Centre Code*: _____________________________________

Village/TownName: ____________________________________

Village Code*: _____________________________________

Anganwadi Worker / ASHA /ANM Name*: ____________________________________

Post Office Name: _____________________________________

Project: _____________________________________

District*: _____________________________________
State/UT*: _____________________________________

Date of Claiming 3rd Instalment by beneficiary*: ---------/-----------/---------------

Date of submission to Supervisor / ANM*: ---------/-----------/---------------


13. Benefits under Janani Suraksha Yojana

i. Did Beneficiary receive incentive under Janani Suraksha Yojana (JSY): YES / NO

ii. If yes, then how much amount was received? .................

13. Checklist of Documents enclosed:

S.No Document to be enclosed (photocopy to be enclosed) Document Enclosed

Yes- Y

1 Aadhaar Card of beneficiary

2 MCP Card with immunisation Details

3 Child Birth Certificate

4 Acknowledgement Slip

Signature/Thumb Impression Date Place

Verification by Supervisor / ANM*

I, Smt. ______________ have verified the information captured in the form and that the form is duly complete.

Signature Name Date Sector Code


-------------------- -------------------------------------------------------------- ------------------------------------------------------

Acknowledgement to be given to beneficiary* (by Anganwadi Worker / ASHA /ANM)

Village/Town Name*: ____________________________________

Anganwadi Centre Code*: _____________________________________

Village Code*: _____________________________________

Anganwadi Worker / ASHA /ANM Name*: ____________________________________

Post Office Name: _____________________________________


Sector Name: _____________________________________
Project/health Block Name: _____________________________________
District*: _____________________________________
State/UT*: _____________________________________
Smt.*___________________ (Name) has submitted duly filled Form 1-C along with documents as per checklist on
_________ (Date).

Signature Date Place

________________________________________________________________________________

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