Rural

Amma Two Wheeler Scheme Application Form 2017-18

Application No
Passport Size
(For Office Use Only) Photo

Dist. Block VP Appl. Running No.

code code code

1 Name of the District

2 Name of the Block

3 Village Panchayat

4 Name of the Applicant

5 Father's name/Husband's Name

6 Sex(Women/Transgender)

7 Permanent Residential address

8 Contact No./Mobile No.

9 Date of Birth / Age (Those aged 18-40
years alone are eligible to apply)
10 Aadhar Number

11 Marital Status Married/Un Married/ Destitute Widow

12 Religion Hindu/Christian/Muslim/
Others(Please specify)
13 Community SC/ST/BC/MBC/OC(Please specify
the sub caste)

14 Educational Qualification

15 Occupation
(Private/Govt. aided organisation or
project/CBOs/shop
establishment/Domestic help/self-
employed/Banking correspondent /ASHA
workers) Please specify
16 a)Name and Address of the workplace

b) Regular commuting distance to work

17 Annual Income
18 a) Date of issue of Driving License / LLR
& Driving License / LLR Number

b) b)Date of expiry of Driving license /

LLR
19 a) Type of the Vehicle proposed to be
purchased (Non-Geared / Auto-Geared
upto 125cc alone are permitted)

b) Total cost of the vehicle as per invoice

/ quotation (on Road price)
20 a) Does the beneficiary propose to buy
the vehicle from her own funds or
through loans from Bank / Finance
institutions? (Please specify)

b) Enclose invoice quotation for the

vehicle to be purchased.

c) If the purchase is through Bank loan,

Name , branch & address of bank /
Finance company from which the
beneficiary seeks loan.

21 Details of the Bank Account of the

applicant
a) Bank Account Number
b) Bank Name
c) Branch
d) IFSC Code

22 Whether the Beneficiary is a member of

any SHG ? If Yes, specify the SHG Name
& Address

23 Whether beneficiary comes under the

following priority?

if yes, Specify.
A) women headed households
B) deserted women
C) Differently abled persons Yes/No
E) Destitute Widow
F) Unmarried women aged above 35
years
G) Scheduled Caste / Tribes
H) Transgender
I) Residing in Hilly region /remote place
24 Copy of Documents to be enclosed
a Aadhar card
b Driving License / LLR (Learner License
Registration)
c Community Certificate (in case of SC/ST)

d Proof of Education (8th pass/fail)

e Proof of Employment
f Salary Certificate from Organisation/
Employer's Certificate/Self declaration for
self employed

g Bank Pass Book First Page with Account

No. & IFSC code

h ID Card from Organisation, if available

i Proof for claim under Priority category as
mentioned in S.No.23

j Invoice / Quotation for the vehicle to be

purchased

Declaration:

1. I declare that all the information & documents submitted by me are true to the
best of my knowledge

2. I voluntarily agree to share my Aadhar number for availing the subsidy given by
the government for the purchase of Auto geared / Non-geared motorised Two
Wheeler.

3. I declare that I have a full-fledged Two Wheeler Driving license on the date of
submitting this application.
(or)
If I applied with a Learner License Registration, I shall produce the full-fledged
driving incense at the time of claiming the subsidy.

Date :

Place : Signature of the Applicant

 Acknowledgement ( to be provided to applicant)

Received Amma Two Wheeler Scheme Application No………………………. from

Selvi./Tmt.……………………………… … D/o,W/o……………… of
……………………………residing at
……………………………………………………...…………on ……….2018.

The following (ticked √) documents were NOT SUBMITTED and must be provided
during field verification. Else, your application is liable to be rejected.

Salary Certificate from

o Aadhar card o Organisation/ Employer's
Certificate/Self declaration for self
employed

o Driving License / LLR

(Learner License
Registration)
o Bank Pass Book First Page with
Account No. & IFSC code

o Community Certificate
(incase of SC/ST) o ID Card from Organisation, if
available

o Proof of Education (8th

pass/fail) o Proof for claim under Priority
category as mentioned in S.No.23

o Proof of Employment o Invoice / Quotation for the vehicle

to be purchased

Signature of the Authorised officer