ORGANISATION PROFILE OF APPLICATION FOR

(OTHER THAN FIRST TIMER)
(PLEASE FILL IN BLOCK/ CAPITAL LETTERS)

CAPART A SS IS TANCE

PART-A : ORGANISATIONAL DETAILS

Name of the Organisation Registered Address Block Police Station District State Pin Code

LOK SEVASHRAM CHIKSAURA AR+P.O: CHIKSAURA (DALLOO BIGHA) HILSA HILSA NALANDA BIHAR 801302

1. 2.1

2.2 Details of Branch Office (S) if any.( Append details of Branch Offices on additional sheets, if
required.) Address Block Police Station District State Pin Code SHANTI NAGAR, SAIDANPORE MORE , HILSA HILSA HILSA NALANDA BIHAR 801302

3.

Contact Numbers
Phone No (1) Phone No (2) Mobile Number Telegram Fax E-mail website Loksevasharam_hil@yahoo.co.in

06111-253556 9934843826

4. Name of contact person(s):LAST NAME 4.1 NAME DESIGNATION 4.2 NAME DESIGNATION PRASAD SECRETARY MIDDLE NAME LAKHAN GENERAL FIRST NAME RADHEY

5. Details of registration (Kindly Enclose copy of relevant certificate (s)) (Please put  against applicable Act) State District : : BIHAR NALANDA :………………… O………………………………………... 950/2002-03

Societies Registration Act, 1860 : ……………………21……………………………………… Indian Trusts, Act,1882

The religious and charitable institutions Registration Act, 1920………………………… If Registered under other Act, Please specify.

5.1

Registration No

( 600 )

Date of Original Registration (27.11.1992) ( PERMANENT )

Registration valid up to :

5.2

Detail of Foreign Contribution Regulation Act,1976 ()

(if applicable, kindly enclose copy of certificate) Date of original Registration : (10.05.2005) Original Registration No (031340099) 6. Registration valid up to ( PERMANENT )

Are there any criminal cases pending against the Organization or office bearers NO (Yes/No)

7. 7.1 7.2 7.3 7.4 7.5 7.6

Detail of people’s representative of the target area (Full name and address to be provided) Lok Sabha Member(MP) Vidhan Sabha member (MLA) Village Sarpanch/gram Pradhan The Collector & District Magistrate Project Director, District Rural Development Agency Block Development Officer : : : : : : SHRI RAM SWAROOP PRASAD SHRI RAM CHARITRA PD. SINGH URMILA DEVI ANAND KISHORE PRAMOD KUMAR ANWAR AHMED , HILSA

8-2 DETAILS OF FUNCTIONARIES (The item is to be filled for each) Name Designation

MEMBER

8.2.2. state whether office held, ion any other VO (s) : Yes/No: NO
8.2.3.Details of the offices held other VO(s) 8.2.4.(in case answer to 8-2-2, is Yes) Name of the Organisation : _________ NO
NO

__________
___________

Address of the Organisation : __________ Name of the Organisation : _________

NO
NO

__________
___________

Address of the Organisation : _________ Name of the Organisation : _________

NO
NO

__________
___________

Address of the Organisation : _________

8-2-4 DETAILS OF RELATIONSHIP WITH CAPART OFFICIALS, IF APPLICABLE. Name of CAPART official Designation : _________ : _________ NO NO __________ __________

Official address Name of CAPART official Designation Official address Name of CAPART official Designation Official address

: _________ : _________ : _________ : _________ : _________ : _________ : _________

NO NO NO NO NO NO NO

__________ __________ __________ __________ __________ __________ __________

8.2.5 Are there any members of the family of the chief. Who receive salary/honorarium from the Organisation? If yes, give details. 8.2.6 Please submit details of personal assets of chief functionary. 8.2.7 Is the chief functionary the founder of the Organisation? If not how years has he been working in rural area ?(Kindly attach his bio-data) Part-B : Details of Activities 9. Activities (please refer to Table:9-1 on Activities codes and give for Multiple activities, give more than one code as demand fit) appropriate codes

9.1.1
Sr. No. 1. 2. 3. 4.

Schemes taken up (CAPART or Others) in past 3 years? Title of S4cheme CONDENG COURSE OF EDUCATION MIDDLE-I CONDENSE COURSE OF EDUCATION , BATCH-II MATRIC CRECHE PROGRAMME FOR CHILDREN BELOW 6 YRS TOTAL SANITATION COMPAIGN Amount Rupees 1,11,250/1,23,500/1,35,820/Completed/ongoi ng COMPLETED ON GOING ON GOING ON GOING Measures taken for sustainability ATTACHED U.C

9.2 9.3

Have you undertaken project involving people’s participation? If yes , state it in 50 word on separate sheet. (YES, ATTACHED ANNEXURE I) Have you undertaken projects for organizing and mobilizing the poor, SC/ST, disabled or women ? if yes, state it in a separate sheet in100 words. Attached separate sheet. (YES)

10

Geographical area of operation Please tick () appropriate code from the list below):(ATTACHED ANNEXURE II ) EARTHQUAKE PRONE (E)  DROUGHT PRONE (P) FLOOD PRONE (F)   TRIBAL (T) REMOTE/ DIFFICULT AREA (R) ANY OTHER (SPECIFY) (O)

COASTAL (C) DESERT (D) HILLY (H)

10.1 10.2

Total number of different Districts in which activities have been undertaken 02 District wise Details:District NALANDA Major Activities codes as per Table-1 Period of time speniworking in the area 15 YEARS

State BIHAR

10.3 is the project for which funding is being taken up I the new area? Yes/no
()

10.4 if yes, then how long do you in word in this area?

N.A

11. MAIN TARGET GROUP (PLEASE GIVE APPROPRIATE CODE FROM LIST BELOW) Agricultural Laborers (A) Bonded Labor (B) Landless Labor (L) Any Other (Specify) (O) 12. Small and marginal farmers Children (C) Women

A

(M) SC (S) Artisans

M S R

(W) Disabled (P) Tribal (T)

W

L O

(R) OTHER VOs (v)

P

PROFESSIONAL STAFF PRESENTLY WORKING IN THE ORGANIZATION (PLEAS GIVE THE NUMBER OF STAFF AGAINST APPROPRIATE ITEM. (Also specify whether full time or part time)

Doctors Homeopaths

Engineers Technologists

Teachers Trainers

08 02

Ayurveds Nutritionists Health Staff Dais Audio-visual Experts Eperts

01 01 01

Geophysicist Economists Social Workers Social Animators Accountants

06 03 01

Lawyers Geologists Veterinarians Foresters Architects Others (pleas specify)3

Chartered Accountants 01

12.1 NO. OF STAFF PRESENTLY WORKING IN THE ORGANIZATION ON:Full time Voluntary 15 08 Part time Total 03 26

Are any existing paid staff rotated to effect of Executive body managing committee of the voluntary Organization? If yes, give detail.

13

DETAILS OF CAPART ASSISTED PROJECTS ALREADY UNDERTAKEN BY THE VO (In Chronological order by the date of sanction)

Si n o

File No

Title of proposal State District Block Village (s)

Locatio n (give)

Particulars of Sanctions

Sanctioned No. of Units And Beneficiaries units

Release Made

Date of Completion / Submission Of UC*

Remarks

D ate 1 2 3 4 5a

CAPART Assistant 5b

Others 5c

Total 5d

Units (Rs.) 6a

SC/ST (Rs.) 6b

OBC (Rs) 6c

Others (Rs.) 6d

D ate 7a

Amount 7b 8 9

N.A

Kindly attach photocopies of UC of completed projects.

PART-C: FINANCIAL STATUS OF ORGANISATION Kindly provide:--

a) Copies of Annual Reports of Last three years (ATT.)

(ATT.)

b) Copies of Audited Statement of accounts of last three years c) Copies of proof of having post office/Bank Account of last three years (ATT. ) d) Copies of permanent Account Number issued by Income Tax department (ATT.) 14. Sr. No 1) 2) 3) INCOME AND EXPENDITURE:Year (Rupees in Lack) 2006-2007 2005-2006 2004-2005 Income (Rupees in Lack) 9,22,923/7,66,268/5,01,488/Expenditure 9,22,923/7,66,268/5,01,488/-

15. Sr. No 1) 2) 3)

RECEIPT & PAYMENT: Year (Rupees in Lack) 2004-2005 2005-2006 2006-2007 Receipt (Rupees in lack) 5,02,531/7,86,321/10,00,811/Payment 5,02,531/7,86,321/10,00,811/-

16. MAJOR ASSETS OF ORGANIZATION AS PER LAST AUDITED BALANCE SHEET (This includes Land, Building with plinth area etc.) Sr. No 1) 2) 3) Cash Deposits Movable assets Immovable Assets Assets Value (Rupees in Lacs) 77,321=00 2,03,416=70 1,12,000=00

(Please Attach list of all movable and immovable assets of value over Rs. 20,000/-) ATT. 17. DETAILS OF BANK ACCOUNT FROM WHICH CAPART FUNDS HAVE BEEN/

PROPOSED TO BE OPERATED. 17.1 Account in the Name of “ LOK SEVASHARAM CHIKSAURA” (Attach photocopy of pass book) 17.2 Details of Bank Accounts:Sr. No 1) 2) 3) 4) 5) Items Name of the Bank Full Branch Address Account Number Type Of Account Name of Signatory (1) Post Held in organization Relationship to chief functionary Name of Signatory(2) Post held in organization Details NALANDA GRAMIN BANK HILSA BRANCH 7562 SAVING A/C RADHEY LAKHAN PRASAD GEN. SECRETARY SELF. Md. BAHAR AHMED TREASURER

6)

17.3 SUMMARY OF RECEIPTS Give details from the Audited statements of accounts for the last 3 years as indicated below:17.3.1 BREAK Receipts
UP OF

RECEIPTS. (Receipt & Payment) Year 2003-2004 Amount % (Rupees) 10,00,811. 2 2,68,079 --2,05,415 5,13,288.7 0 100 % 27 % ---20.5% 51.3% 2,10,160 3,98,937 51 % Year 2004-2005 Amount % (Rupees) 7,86,321 1,75,480 22.3 % 26.7 % --1,33,27 0 3,06,07 5 Year 2005-06 Amount % (Rupees ) 5,02,53 100 % 1 61,530 12 % ---26.5 % 61 %

Total funds Received From Government From Foreign Source Own Source By Community Contributions

17.3.2 What percentage of total expenditure was spent on administration last year?

17.3.3 Break up of Administration expenditure in percentage: Clarification on page. Sr. Administrative Amount (in Rupees) Percentage No Expenditure 1) 2) 3) 4) 5) 6) 7) Salary/emolument 21,000/s Facilities for Staff 3,518/Fuel, oil, lubricants Travel 4,786/Telephone Office expenses(Rent) Any Other Total --------8,244/4,418/41,966/-

17.3.4 Has your organization been black listed/put understanding restrictions by CAPART/ Any Other organization? ( NO) If Yes, Give details. 18. Are Annual Reports and Audited statement freely available to any member of The public? Yes/No (YES). If no, the reasons thereof __________________

19. Certified that the information given in this form is correct to the best of our knowledge. It is understand that tendering false information will result in CAPART recalling the assistance and stopping further funding of the VO. Counter signed by Member of the Executive body

Name:

Authorized Signatory

Designation:

Name: Designation:

Place: Date:

SEAL OF THE ORGANIZATION

FOR CAPART USE ONLY Computer Generated Number allotted:-

Date

Signature

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