(FILLED UP FORM SHOULD BE SUBMITTED TO AUTHORISED PERSONS ONLY) Form 1-C APPLICATION FORM FOR CLAIM OF THIRD INSTALLMENT UNDER PMMVY 4. Name of the Beneficiary” 2. Aadhaar/identity number of beneficiary*; ——————— The criterla for determining socially and economically this advantaged sections of society will be the following : i. Women belonging scheduled castes and scheduled tribes. ii, Women who are partially(40%) or fully disabled (Divyang Jan). ili, Women holder of BPL ration card. iv. Women Beneficiaries under Pradhan Mantri Jan Arogya Yojona (PMJAY) under Ayushman Bharat. v. Women holding E- Shram Card, vi. Women Farmers who are beneficiaries under Kissan Samman Nidhi, vii. Women holding MGNREGA job card. viii. Women whose net family income is less than Rs. 8 Lakh per anum. ix. Pregnant and lactating AWWs, AWHs, ASHAs. 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. Ifyes, Name of Government approved facility, 5. Tick yes, if already registered under the scheme() Yes, No (If no, then fill Form 1-AV(f yes, enclose copy of Acknowledgement Slip)* 6. Gender of Child/ Children*: a.cMale cFemale (Please tick) In case of multiple births, fll the following: b.oMale — oFemale (Please tick) _ (in case of twins) coMale Female (Please tick) _ (in case of triplets) d.cMale cfemale (Please tick) _ (in case of quadruplets) 2. C6 or equivalent/substitute: D Yer No b. OPV or equivalent/substitute: D Yes No DPT oF equivalent/substitutes> Yes > No 4. Hepatitis: B or equivalent/substitute: D> Yes No12. Details to be filled Anganwadi Worker / ASHA /ANM ‘Anganwadi Centre Name/Approved Health Facility Name: Anganwadi Centre Code*: Village/TownNar Village Code” Anganwadi Worker / ASHA /ANM Name": Post Office Name: Project District® State/UT*: Date of Claiming 3" instalment by beneficiary*: Date of submission to Supervisor / ANM*: ~~ 13, Benefits under Janani Suraksha Yojana |. Did Beneficiary receive incentive under Janani Suraksha Yojana (JSY}: YES / NO I yes, then how much amount was received? 13. Checklist of Documents enclos 'S1No | Document to be enclosed (photocopy to be enclosed) | Document Enclosed Yes: 1 | Aadhaar Cord of beneficiary 2 _ | MCP Card with immunisation Details, 3 | Child Birth Certificate 4 | Acknowledgement Sip Signature/Thumb impression Date Place Verification by Supervisor / ANM* 1st have verified the information captured in the form and that the form is duly complete. Signature Name Date Sector Code3< 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 ith documents as per checklist on (Date). Signature Date Place