URBAN (Annexure – C1)

Amma Two Wheeler Scheme Application Form 2017-18

Application No:
(for office use)

1 Name of the District

Name of the Corporation/ Municipality/ Town
2
Panchayat

3 No. of ward / Division / Zone

4 Name of the Applicant

5 Father's name/Husband's Name

6 Sex(Women/Transgender)

7 Permanent Residential address

8 Contact No./Mobile No.

Date of Birth / Age (Those aged 18-40 years

9
alone are eligible to apply)

10 Aadhar Number

11 Marital Status Married/UnMarried/Widow

Hindu/Christian/Muslim/ Others(Please
12 Religion
specify)
SC/ST/BC/MBC/OC(Please specify the
13 Community
subcaste)

14 Educational Qualification

Occupation
(Private/Govt. aided organisation or project/CBOs/shop
15
establishment/Domestic help/self-employed/Banking
correspondence/ASHA workers) Please specify

a)Name and Address of the workplace

16
b) Regular commuting distance to work

17 Annual Income

a)Date of issue of Driving License & Driving

License Number
18
b)Date of expiry of Driving license

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 Amma Two Wheeler Scheme Application Form 2017-18
a)Type of the Vehicle proposed to be
purchased (Non-Geared / Auto-Geared upto
125cc alone are permitted)
19
b) Total cost of the vehicle as per invoice /
quotation (on Road price)
a) Does the beneficiary propose to buy the
vehicle from her own funds or through loans
from Bank / Finance institutions? (Please
specify)
b) Enclose invoice quotation for the vehicle to
20
be purchased.

c) If the purchase is through Bank loan, Name ,

branch & address of bank / Finance company
from which the beneficiary seeks loan.

21 Details of the Bank Account of the applicant

a) Bank Account Number

b)Bank name

c )Branch

d)IFSC Code

Whether the Beneficiary is a member of any

22
SHG ? If Yes, specify the SHG Name & Address
whether beneficiary comes under the
23 Yes/No
following priority?
if yes, Specify.
A) women headed households
B) deserted women
C) Differently abled persons
E) destitutes
F) unmarried women aged above 35 years
G) Scheduled Caste / Tribes
H) Transgenders
I) Residing in Hilly region /remote place

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 Amma Two Wheeler Scheme Application Form 2017-18
24 Copy of Documents to be enclosed
a Aadhar card
b Driving License
c Community Certificate (incase of SC/ST)
d Proof of Education (8th pass/fail)
e Proof of Employment
Salary Certificate from Organisation/
f Employer's Certificate/Self declaration for self
employed
Bank Pass Book First Page with Account No. &
g
IFSC code
h ID Card from Organisation, if available
Proof for claim under Priority category as
i
mentioned in S.No.24
Invoice / Quotation for the vehicle to be
j
purchased
Declaration:
1. I declare that all the information & documents submitted by me are true to the best of my
knowledge
2. I voluntarily agree to share my Aadhar number for availing the subsidy given by the
government for the purchase of Auto geared/non-geared motorised two wheeler.

Date:

Place: Signature of the Applicant

Acknowledgement ( to be provided to applicant)

Received Amma Two Wheeler Scheme Application No………………………. from
Selvi./Tmt.………………………………………… D/o,W/o of ……………………………residing at
……………………………………………………...…………on ……….2018. The following (ticked √) documents
were NOT SUBMITTED and must be provided during field verification. Else, your application is
liable to be rejected.
⃝ Salary Certificate from Organisation/
⃝ Aadhar card Employer's Certificate/Self declaration for self
employed
⃝ Bank Pass Book First Page with Account No.
⃝ Driving License
& IFSC code
⃝Community Certificate (incase of SC/ST) ⃝ ID Card from Organisation, if available
⃝ Proof for claim under Priority category as
⃝ Proof of Education (8th pass/fail)
mentioned in S.No.23
⃝ Invoice / Quotation for the vehicle to be
⃝ Proof of Employment
purchased

Signature of the Authorised officer:

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Amma Two Wheeler Scheme Application Form 2017-18

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