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Janani Suraksha Yojana (JSY)

Fund utilization & Requesting Form


Arogyakeralam Malappuram

Name of the PHC: .


Statement of Expenditure Total No. of Expenditure beneficiaries Details Total assisted BPL :..... SC ST :. :.........
.. X Rs.700 .. X Rs.600 .. X Rs.500

Date: ..

Opening Balance

Closing Balance

No. of beneficiary BPL :..... SC ST :. :.........

Requested Details Details


.. X Rs.700 .. X Rs.600 .. X Rs.500

Amount

Total: Total Amount : Total:

Total No. of beneficiaries assisted by ASHA:.. HI/LHI M.O

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