FORM

FROM M.B.I

APPLICATION FROM FOR MATERNITY BENEFIT

 ( To be filled up by the applicant )

District :                                                                                 Block / Panchayet / Samiti / Municipality

Village / Panchayat / Mohalla / Ward / House No.

1.    Shrimati :

2.    Name of husband :

3.    Full Address :

4.    Categories : SC / ST / Women / Landless / Handicapped / General.

5.    Age on the date of application :

6.    Identification mark of the applicant :

7.    I solemly affirm that :

        1)     I do not have any family income of Rs. 5.000/- per annum or more.

        2)     This is my application with regard the FIRST / SECOND Pregnancy.

        3)     I am a resident of ......................................................................................

                ( District / Sate ) Where I have been residing during the three years immediately preceding the date of                   this application.

        4)     I declared that the information furnished in this application is true / correct to the best of my knowledge                  and belief.

            Place :

            Date :

                                                                                                             Signature or Thump impression

                                                                                                                        of the applicant