ASSAM	FINANCIAL	CORPORATION
MICRO FINANCE & NE W BUSINESS BRANCH
“Vittiya Bhavan”, Md. Shah Road, Paltanbazar, Guw ahati-781008
Ph. : 2739839,  2633658.  Fax: 0361-2519859.
E-mail: afcmicro@ gmail.com  Url:   www.afconline.gov.in

APPLIC ATION FORM FOR LOAN UNDER
CHIEF MINISTER’S MICRO FINANCE SCHEME - “KHUDRA REEN”

1	Name of the Organisation		
2	Address	Registered   Office	Address for
Correspondence	
	
House No.			
	Street/Road Name			
	Village/ward No.			
	P.O.			
	P.S.			
	Block			
	District			
	Pin Code			
	State			
	Phone Number	Land line :	Mobile :	
	E-mail address			
	Website			
3	Constitution

4	Loan Amount applied for		

Seal & Signature  of authorised  signatory(ies)

- 1 -

5	Authority with whom registered		
	Registration Number & Date of Registration		
	Registration Valid up to		
	Details of other Registrations with Number, Date and Validity, if any.		

6	
Whether  the  Memorandum of Association/Bye- Law permits the organization to borrow and lend money. If yes, mention the Clause No. of MoA/Bye-Law.		
8	Year of starting of
Micro Finance Programme (Attach Balance Sheet/ Loan Ledger Abstract of the year of commencing Micro Fina nce)		
9	Area of Operation in Assam
(Mention name of Districts)		
10	Details of Banker(s) of the
Organisation :		
	Name of Bank with Address	Type of Account	Account No(s)	

				

Seal & Signature  of authorised  signatory(ies)

- 2 -

11. Particulars of Chief Functionaries:-

Name	Address	Tel/ Mobile  No	Designation	Qualification	Age
(Yrs)	Years of experience in Micro  Finance	Photographs of Chief Functionaries
(Self attested)	

								

								

Seal  &   Signature of authorised signatory(ies) 	(Attach  additional sheet   if require d)

Name	Address	Tel/ Mobile   No	Designation	Qualification	Age
(Yrs)	Years of experience in Micro   Finance	Photographs of   Chief Functionaries
(Self attested)	

								

								

Seal  &  Signature of  authorised signatmy(ies) 	(Attach additional sheet   if  require d)

- 5 -

Category	
Staff Trained in Micro- Finance operation	
Others	
Total staff	

Field Supervisory Officer & Staff				

Supervisory Officer & Staff				
General Staff				
Total				

13 (B). Details of participation in training programme by the Chief Functionaries/Executive Members/others (enclose photocopy of certificates)

Sl. No.	Name of Participant	Name of Training
Programme	Training Programme conducted by	Duration	

					

Seal  &  Signature  of authorised  signat or y(ies)	(Attach  additional sheet  if required)

- 6 -

Year	Amount of Loan Disbursed	Activities for which loan extended	Financial assistance extended to total number of :	Amount
Recovered	
			SHGs	JLGs	Male
Borrowers	Female
Borrowers	Total
Borrowers		

									

Seal & Signature  of authorised  signatory(ies)	(Attach additional  sheet if required)

- 7 -

Sl. No.	Name of Bank/Organization from whom loan availed	Year of availing loan	Loan Amount
Availed	Rate of Interest	Loan Amount
Repaid	Amount of Loan
Outstanding
(as on ______)	

							

Seal & Signature  of authorised  signatory(ies)	(Attach additional  sheet if required)

Name  of Bank/Organi zation with  whom  loan  applie d and or from  whom loan availed	
Loan Amount Applied for	
Loan Am ount Availed	Estimat ed num ber of beneficiaries prop ose d to be covered	
			
SH Gs	
JLGs	Male
Borrowers	Female
Borrowers	

							

							

00

Seal  &  Signature  of authorised  signator y(ies)

DECLARATION

I/we hereby declare that the information furnished above is true to the best of my /our knowledge and belief. There are no over dues / statutory dues pending with any Bank/ Financial Institutions etc and no legal action has been /is being initiated against the organisation.

Date: ……………..……….	Signature of Authorised Signatory/ies. with Name, Designation & Seal
Place: …………………….

1……………………………………....................…….
…………………………………......................………. Name & Designation & Seal

2……………………....................…………………….
………………………......................…………………. Name & Designation & Seal

3……………………....................…………………….
…………………......................………………………. Name & Designation & Seal

- 9 -

LIST OF DOCUMENTS TO BE SUBMITTED ALONG WITH THE APPLIC ATION FORM

1.	Copy of Article of Association, Memorandum of Association and Bye-Law of the organisation

2.	Copy of Valid Registration Certificate(s) issued by competent Authority.

3.	Copy of Resolution passed by the Board/EC on the following :

•		Allowing the concern to borrow Loan from Assam Financial Corporation, Guwahati for on-lending to SHGs/JLGs.

•	The Rate of Interest	to be   charged from the beneficiaries shall not exceed 20%
p.a on Reducing  Balance including all charges.

•		Authenticate   the  name(s)   &  designation   of  authorised   signatory   (ies)  w ho shall communicate,  sign and  execute deeds & conduct all      official correspondences   &  financial   transactions   with  Assam  Financial   Corporation   on behalf of the Organization..

4.	Duly signed Bio-Data of the Chief Functionaries.

5.        Copies of Audited Financial  Statements/Balance  Sheet along with Schedules    and with separate   sheet of income  & expenditure  and   receipt  & payments  statement pertaining to micro finance operation  exclusively for the last 3 (three) years.

6.	Copies of Annual Reports duly approved by the Annual General	Meeting (attach copy of
                Minutes/Proceedings)  for the last 3 (three) years.

7.	Self attested Passport size Photographs of the Chief Functionaries &  Executive  Members.

8.       Residential Address (both temporary and permanent) of the Chief Functionaries,  Directors and Executive Members with documentary proof .

9.	Photocopies of Pan Card of Chief Functionaries, Directors and Authorised signatories.

10.    Reference   Letter   from   two   referees   of   social   repute,   one   of  whom   should   be preferably from Bank or Financial Institution.

11.	Copy of latest Report on rating of the organisation, if available.

12.	Procedure for affixing Common Seal of the organisation to be intimated (for NBFC etc.)

13.	Duly filled up enclosed statements from Sl No. 1 to 9 pertaining to  Micro  Finance Operation.

14.	Business plan for utilization of proposed loan fund.

15.	Copies of Operation Manual, Audit Manual, Credit Manual, H.R. Manual, if available.

16.	Summary Report on Management Information System.

17.	Copies of Proceedings/ Minutes  of last 3 (three) Executive Committee/Board Meeting.

18.	Loan Loss Reserve and Policy for loan loss and write off, if available.

19.	Client dropout list.

NB:
1.    Loan Application  Form shall be treated as submitted only on receipt of completely  filled in loan form along with the enclosed statements (sl. no. from 1 to 9) and the required documents as stated above.
2.	Documents to be submitted in a chronological order as per the above list

Loan Portfolio Outstanding Statement for last 3(three) years:

Financial
Year	

Opening Outstanding of Loan Portfolio	

Amount
Disbursed	

Amount due during the year	

Amount Recovered	
Total Recovery during the year	
Closing Outstanding of Loan Portfolio	

Closing Over Dues	
			
Principal	
Interest	Current
Principal	Current
Interest	Arrear
Principal	Arrear
Interest				
FY:	

											
FY:												
FY:												

Due /Receipt Statements for all loan accounts (Loan Account wise) for the period................. tto ……………….___
____________________________________________
_____

S.L No	

Name of the
SHG/JLG/Individual Loan	

Code No, if any	
Opening loan outstanding as on ______	

Amt
Disbursed	
Date of Disbursement 	Amount Due during the
Period _____ to ______.
	Amount Recovered during the period	

Loan Outstanding as on ________	
						
Principal	
Interest	
Principal	
Interest		

1											

2											

3											

4											

5											

6											

7											

8											

9											

10											

11											

12											

13											

Attach separate sheet , if required

Statement-3
Amount in `(rupees)

Over Due Statement (Account Wise) of over due loan accounts for the period ……………… to …………………… _____________________________________________

S.L No	

Name of the
SHG/JLG	

Code No	
Opening Overdue  as on
_______	Amount due during the period _______to ________
	
Amount recovered during the period	
Closing overdue as on________	
Total Over due as on ______	

Loan Outstanding as on
_______	
			
Principal	
Interest	
Principal	
Interest	
Principal	
Interest	
Principal	
Interest	
(Principal + Interest)		
1													
2													
3													
4													
5													
6													
7													
8													
9													
10													
11													
12													
13													
14													

Attach separate sheet, if required

Statement- 4	Amount in ` ( rupees).

Statement of loan loss accounts( Account  wise)  for the period ……….. to ……………..

S.L No	

Name of the
SHG/JLG	

Code No	
Opening Overdue  as on _____	
Amount due During the period ____ to ______	
Amount recovered during the period	
Amount of  Over Due as on ______	
Closing overdue as on _____	
Age of Over Due
(Days)	
			
Prin + Intt.	
Principal	
Interest	
Principal	
Interest	
Principal	
Interest	
Prin + Intt.		

1												
2												
3												
4												
5												
6												
7												
8												
9												
10												
11												
12												

Attach separate sheet , if required

Data/Information  pertaining to micro finance operation for last 3(three) years:

Sl No.	Particulars	FY:	FY:	FY:	
1	No of Staff in Micro Finance Operation				
2	No of Credit Officers				
3	No. of members				
4	No of W omen Members				
5	No. of borrowers				
6	Nos of W omen Borrowers				
7	Nos of SHGs				
8	No of JLGs				
9	Portfolios at Risk ( >30 days)				
10	Rate of Interest of lending( Flat/Reducing)				
11	Frequency of Repayment by the SHGs/JLGs				
12	Processing Fee /Service Charge per loan				
13	Loan Application Cost				
14	Security Deposit per loan				

Statement-6

Income Statement of  Micro Finance  Operation for last 3(three) years:	` in lacs

S.L No	Particulars	FY:	FY:	FY:	
1	Interest Income (Current)				
2	Interest Income (Arrear)				
3	Interest on Investment				
4	Service Charge Income				
5	Late Fee Payment  Charge Income				
6	Other receipt/Income				
	Total				

Expenditure Statement of Micro Finance Operation for last 3(three) years:	` in lacs

S.L No	Particulars	FY:	FY:	FY:	
1	Interest paid on borrowing				
2	Other Interest paid				
3	Salaries and Incentives.				

4	
Administrative Expenses (rent, telephone, printing &
stationery, bank charges ,commission etc)				
5	Travelling Expenses				
6	Depreciation				
7	Other Expenses				
8	Provision for loan loss				
	Totall				

Consolidated Overdue Statement of the loan accounts for last 3(three) Financial Years

` in lacs

Statement-8

Financial
Year	

Opening outstanding of Loan Portfolio	

Amount Disbursed during the year	
Opening overdue	
Amount due during the Year	
Total due During the Year	
Amount recovered	
Closing Over Due	

Closing outstanding of Loan Portfolio	
			
Principal	
Interest	
Principal	
Interest	
Principal	
Interest	Principal
out of Current Due	Principal
out of Arear due	
Prepayment of
Principal	
Interest	
Principal	
Interest		

FY:																

FY:																

FY:																

Statement-9
Balance Sheet for Micro Finance Operation for last 3(three) years.

ASSETS	FY:	FY:	FY:	
Cash and Bank Balance
(current accounts)				
Interest-bearing deposits				
Loan outstanding				
Current due loan				
Past-due loan				
Restructured loan				

Other current assets				
Long term investments				
Property and equipment (at Cost )				
Revaluation of fixed assets				
Less (Accumulated depreciation)				
Net property and equipment				
TOTAL ASSETS				
				
LIABILITIES				

Short term borrowings
(commercial rate)				
Deposits, if any				
	
Long term debt (commercial rate)				
Long term debt (concessional rate)				
				
Loan Loss Reserve (Provisioning
for loan loss)				
TOTAL LIABILITIES				

EQUITY				
Loan fund capital				
Inflation adjustment-equity				

Retained net surplus (deficit) prior years				
Current-year net surplus (deficit)