(Note : Application received in an incomplete form will not be entertained).

Part - I
(TO BE COMPLETED BY THE APPLICANT)

1. Name of the Institution/Organisation.

2. Objectives of the Institution/Organisation.

3. Brief history of the Institution/Organisation
   and of its objects and activities,

4. Whether recognised by the State Government.

5. Whether registered under Indian Societies
   Registration Act (Act XXI of 1860).
   If so, give the number and date of registration.

6. Whether the Institution/Organisation
   of all India character :
   If so, give the nature of its all India character.

7. Whether located in its own/rented building.

8. Whether the project is likely to be assisted
   by some other official or (non-official Source.

   If so, give detail thereof.

9. Justification for the project indicating its
   important features which entitle it to central
   assistance.

10. Total estimates expenditure on the Short Stay Home for one year :

(i) Non-recurring .... Rs.

(ii) Recurring Rs.

(b) Period for which recurring assistance is required.

11. Amount of grant requested Estimated Expenditure :

(i) Non-recurring Rs.

(ii) Recurring Rs.

(b) Period for which recurring assistance is required.

12. Is accommodation available for running
    the Short Stay Home or temporary shelter
    is proposed to be improvised ?

Proposed location of Short Stay Home with full address.

13. Whether the institution is in a position to
    meet excess expenditure ? If so, indicate the Sources.

14. List of papers/statements to be attached
   (in duplicate)

(a) Prospects or a note giving aims and objects
    of the Institution/Organisation.

(b) Constitution of the Institution/Organisation.

(c) Constitution of the Board of Management with
    brief particulars of each member.

(d) Latest available annual report.

(e) Audited accounts for the last two years along
    with a copy of the certified balance sheet for
    the previous year.

(f) A statement giving details (year, purpose,
    amount etc.) of assistance received during
    the last two years from the Central/State
    Governments. Central Social Welfare Board.

Local Bodies or any other quasi-Government
institutions including requests made thereof
to any of those or any other organisation for
the project under consideration or for any other
 project.

(g) statement giving item-wise and year-wise
    of estimated recurring & non-recurring
    expenditure on the proposed project.

15. List of additional papers, if any.

16. Additional information, if any.

17. Does the Institution/Organisation work
    for profit to any individual on body
    of individuals ?

Signature of Secretary/President

PART-II**

(To be filled by the State Government in respect of State level or local organisations)