TEMPLATE - I (A) Basic information to be submitted by Implementing Agency to State/ Divisional Office of KVIC while submission of proposal for SFURTI cluster) (i [etuster Category [oRegular Major = Name of Cluster Tocation of the Cluster BEALE ann District Villages Survey NO» [Industry 1 Rhadi village industry....... (Specify) ‘Current Product Portfolio %. | Name of Implementing Agency (TA) With postal Address Project objectives 8. | Key Gaps Identified ‘9, | Area to be covered by the cluster i, No, of villages to be covered i, Name of the villages & artisans available Sr. | Village ‘Artisans available Name | SC | ST | OBC] Minority | Others | Total Male | Female en] 5} co] a) ) Total Page 12 of 41iil, (Enclose details in an Annexure in tabular Form); Sr. | Name | Contact| Adhar | Skills | Details | Livelihood Existing Average No.| of the | no. | Card/ ofBank | Levels | Employment(No. | Income of Artisan Election Alc. of working. Artisan. IDNo. iG hours/No. of | (p.m.) see daysin a month) | T 2 10. | Details of Artisans in respect of following documents ( For existing artisans) Yes No Bank Passbook Yes No Identity card Yes Health Insurance Yes No iv, Janshree Bima Yojana Yes No v. Pension coverage Yes No vi. Educational benefits availed for children under JBCRY_ 11. | Whether the cluster is existent/ functional or new one? give details: Present Activities of the cluster ‘A. (Incase of Khadi institution) Spinning activities Weaving activities Processing activities : Products etc. B. (In case of activities under V.I. Institution) Processing activities Products ete, 12. | Name of other associated institutions who are willing to take part in the cluster; (applicable to only Khadi Clusters) Sr. | Name@address ofthe | Affiliated to Contact no. e-mail ID No. associated IA KVIC/KVIB 1 Yes/No 2 Yes/No. 3 Yes/No (All the associate institutions should sul ibmit information as per Template I (B)) Page 13 of 4113, | Proposed Interventions a)Hard Interventions (New) Hard Infrastructure Facility | Constructed | Machinery/ | Cost Interventions Area/CFCto | Equipments | (Rs.) be constructed CFC/RMB/Marketing infrastructure ‘b)_Replacement/ upgradation of Charkhas/looms/tools Replacement/ No. of | Unit cost | Total cost upgradation of | beneficiaries (Rs.) (Rs,) Charkhas/looms/tools, ‘C) Any other Soft Interventions Proposed | No. of | Cost Interventions activities | Beneficiaries | _(Rs.) tobe imparted training/involv ed a) Skill training b) Capacity Building ¢) Market Promoti <) Others 14, _| Total Project cost Rs.) 15, _ | Detailed Project cost (Rs. (Core SFURTI) 16, _| Source of Funds 7 Means of Finance (Rs.) 17, _ | Phasing of the Project Page 14 of 4118. | Project 1 Whether the |.A..is considered to be the SPV... Implementation 1» (give details) (only for kis ofkvIc) Framework/ Proposed SPV Structure © Whether an SPV is being separately registered If yes, ‘ive details along with proposed SPV structure: 19. | Mobilisation of Working Capital 20% of hard interventions cost will be utilized towards purchase of Raw Materials (RMB) as per the guideline. Provide the projection of Working Capital based on related activities on Quarterly/half yearly /annual basis. 20. | Details of the existing Cluster and the infrastructure facilities available with |.A. A. Existing infrastructure available with the LA. i. Land Area (sq. ft) Built up area Machineries ... : iv, Tools available with the artisans namely (may vary based on the activity) vy. Charkhas NMC. Traditional .... - Looms . Improved. Traditional. vii, Others B, Source of raw materials within the cluster area ‘Sr. | Particularofthe raw | Source institution/ | Annual Quantity Cost materials Artisans/ Local (approx) (Rs.) Page 15 of 4121. _| Indicate the “Product” to be manufactured under the cluster and projection of Sale value and margin etc. Sr. | Name ofthe | Quantity Overall Proposed | Margin /Profit on No. | Product to be Production | Sales Value | — monthly basis produced Cost (Rs.) 1 ; 3 ; = 22. _ | Projection of Artisan wages over the duration of the cluster: 23. | a.) Availability of Forward Backward Linkages (with assured target) b) Plan / initiatives / schemes for convergence ¢.) Enhanced Project cost and means of finance 24. | Key Impacts 1 2, 3, 4 25 | Resolution of Implementing Agency: the cluster along (8) {Enclose specific resolution approving the functions of all the target proposed as brought out in the proposal under Template-! (A) and | Treasurer(I.A.) Secretary(I.A.) Supporting documents as under should be enclosed: Registration Certificate ofthe Institution & its validity. Resolution from IA/NGO for implementation of SFURTI scheme Details of land records owned by IA. and Building construction if any Details of SPV registration, if registered List of artisans (Village wise in the prescribed format) Chairman(1.A.) Balance Sheet and Statement of Accounts for the last 3 years and /or undertaking for contribution of IA share. Page 16 of 41TEMPLATE - I (B) Profile of the Implementing Agency (1.A.) 1 Institutional Structure/Registration Details 1 Legal Status O Central/State Governments Institution 0 Society (Under Societies Registration Act,1860) 0 Co-operative Society (Under appropriate Status) (Registered as Trust O_ Proprietary firm/partnership (]__ Registered Under Companies Act,2013 1 Private Limited Company CO Public Limited Company 1 Company under Section 0 Producer Company under Section465 (1) O Other(Specify) # Date of Incorporation/ Attach Certificate of Incorporation. Registration 3 Registered Postal Address : 4 Office Postal Address/Locations 5 Affiliated to KVIC Yes/No. If yes, provide Certificate No.. Validity of Certificate, wn Governance Structure 6 Sr. Name of | Designati | Background/ | Contact | Email Executive Board/ No. Member on Profile Number Trustees/Governing Body/Managing | 1. Committee and 2. iE Page 17 of 41Background of Members Not Available 7 [in case, 1A is|Sr. | Nameof |Background/Profile | Shareholding (%) registered under | No._|_Member Companies Act, provide shareholding pattern Not Available al Mi | Operational Profile 8 | Major Objectives-Vision, Mission, Goal of the Organization ‘9 | What are focus areas of operational _[l b. B. 10 | Provide key projects/activities being undertaken by the-—IA-Brief description including the project, scope, size and duration (mention specific experience in the area/sector of the proposed project) 11 [Mention key _clients/donors _ associated with for _project implementation along with details on the nature of association 12_| Mention key partnerships/alliances (fany) 1V_| Management Profile 13 [Background of key Personal (Professionals and others) with brief profile of the senior management personnel) Page 18 of 41V__| Financial Position 14 | Key financials of the Organization | Fixed Assets, (Provide copy of the audited | Current Assets financial statements for last 3years) | Current Liabilities a Revenue trend for fast 3 years Profit/Loss for the last 3 years ISEC availedincase | Yes No of KVIC/KVIB Inst. “Amount of ISEC availed during last three years ‘Any other Vi__| Bank Account Details 35 | Name of Bank 16 | Branch Name 17 | Bank Account Number | 18 | iFSCcode Vil _| Contact Details 19 | Name of Contact Person 20 | Designation of Contact Person 21 __| Correspondence Address 22 | Contact Number 23 | E-mail Address It PAN/TAN 2.6ST Number | DARPAN No. 4.Udyog Aadhaar/ MSME Regn. No. Treasurer (LA) Secretary(lA) Chairman(1.A.) Page 19 of 41