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Amma Two Wheeler Scheme 2017 -18

Subsidy Release Claim Form


Application No.________
On receipt of registration certificate and the physical verification of
the purchase of the two wheeler, the subsidy will be released to the
beneficiary’s loan account/ bank account.

1 Name

2 Address

3 Father / Husband Name

4 Type & Date of manufacture of


vehicle
5 Registration Number &
Date of Registration R.C No.--------------------------

(Copy to be enclosed) Date ------------------------------

6 Driving License No.

Date of issue of License.

(Copy to be enclosed)
7 If vehicle bought from own funds,
please specify saving account
details
:
OR
If vehicle bought through Loan
specify loan account details.

(i) Bank Account No.

1
(ii) Bank Account type: Savings/ Loan

(iii) Bank Name &Branch

(iv) IFSC Code :

8 Cost of Vehicle on Road Price


(Inclusive of Rd.Tax, Insurance etc.)
9 Subsidy Amount claimed (Maximum
of Rs.25,000/- or 50% of vehicle Rs………………
cost given in column 8 )

I certify that I have a full – fledged Motorised / Two Wheeler


Driving License on the date of applying for the Subsidy Claim form.

Date :

Place :

Signature of the Beneficiary Signature of Bank Manager /


Finance Company(with office seal)

……………………………………………………………………………………

For Office Use Only

Verified the above claim and found correct / incorrect. Hence, the
claim is recommended / Not Recommended for the release of the
subsidy amount Rs……………by the Selection Committee.

If the claim is not recommended please give the specific reasons


below:

(i) ……………………………

(ii) …………………..………

Date: PROJECT DIRECTOR TNSRLM

.............................DISTRICT

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