Government of West Bengal

Child Development Dept. & Women Development and Social Welfare Dept.
[To be filled up in English Block letters only]
KANYASHREE PRAKALPA-Up-Gradation [K2] FORM - NORMAL

Applicant ID : 19190702502170000029
Name : SUSMITA GHORAI
D.O.B : 03-03-2002
Institute Name : ATATTAR HIGH SCHOOL

Applicant Basic Details

Religion * ❏ Hindu ❏ Islam ❏ Buddhist ❏ Sikhism ❏ Chirstanity ❏ Others
Catergory * ❏ General ❏ SC ❏ ST ❏ OBC ❏ Others
Standard * ❏ VIII ❏ IX ❏ X ❏ XI ❏ XII ❏ College
Both Father & Mother Deceased * ❏ Yes ❏ No
Differently Abled * ❏ Yes ❏ No % of Disability(as per certificate)

Aadhar Card * ❏ Yes ❏ No Aadhaar Card No(if Yes)

Mobile No * +91

Applicant Bank Details

Bank Name
Account No 59045661122
IFSC Code ALLA0211493

Applicant Contact Details

Present Address *
House No :
Road / Street :
Post Office :
Police Station :
District :
State :
Pin :

Permanent Address [ ❏ Same as Present Address ]

House No :
Road / Street :
Post Office :
Police Station :
District :
State :
Pin :
 Form Serial No : 0649078
A. Applicant’s Declaration

❏ I declare that I am the applicant mentioned in this application.The following documents are submitted with this application (Tick
applicable)

Certificate of Eligiblity

❏ Applicants staying at Home under JJ Act are excempted from producing the following documents.

❏ Declaration that I am UNMARRIED. (certified by Competent Authority)

❏ Copy of Birth Certificate attested by applicant. I understand that my daughted/ward will not be eligible to apply for renewal of
Kanyashree Annual Scholarship/Upgrade to Kanyshree One time grant next year unless I can provide her birth certificate issued by
the appropriate panchayat/municipal authority.

If Applicant’s Mother and Father are Deceased

❏ Declaration by applicant that both parents of the applicant are deceased certified by Competent Authority.

❏ Copy of Death Certificates of mother and father (if both parents are deceased) attested by applicant.

If Applicant is Specially Abled

❏ Copy of Certificate of Disablity attested by applicant.

Other Documents ( If available )

❏ Copy of Bank Pass book showing bank account details.

❏ Copy of AADHAAR card attested by applicant.

(If AADHAAR card has been provided) I, the applicant given consent do not given consent to the use of my AADHAAR number for
authenticating my identity for Kanyashree Prakalpa.

Date:____/____/________ ___________________________________ ___________________________________

Applicant’s Signature Signature/Left Thumb-impression of
parent/legal guardian

B. Parent’s / Legal Guardian’s Declaration

❏ I declare that I am the father / mother / legal guardian of the applicant, and that her declaration and the documents provided
are true.

Date:____/____/________ ___________________________________ ___________________________________

Applicant’s Signature Signature/Left Thumb-impression of
parent/legal guardian

C. Certification by Superintendent of J.J. Home

❏ I, hereby certify that the applicant mentioned in this application is presently residing in this institution (J.J. Home) and is
unmarried.

Date:____/____/________ ___________________________________
Signature of Superintendent of J.J. Home with Office Seal

D. Certification by Head of Institution

❏ I certify that the applicant mentioned in this application is enrolled and regularly attending this institution. I also certify that I
have verified the information given in this application with the documents submitted and certify that she is eligible for the One-Time
Grant.

Date:____/____/________ ___________________________________
Signature of Head of Institution with Office Seal
Administrative Use
Data entered into portal by ___________________________________ on ____/____/________
Data verified by ___________________________________ on ____/____/________
Application sanctioned by ___________________________________ on ____/____/________
.................................................................................................................................................................................................................

Acknowledgement Received
SUSMITA GHORAI (19190702502170000029) daughter / ward of BHOLANATH GHORAI residing at PURBA MEDINIPUR
NANDIGRAM -III 721633 have applied for Up-Gradation of Kanyashree Prakalpa for the year 2019-2020.

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