Annexure - 1: Application Form

Part-I

1. Name of the Unit

2. Address:
Office:
Factory:
Tele No. :
Fax No. :
Email:
3. Constitution of the Unit Proprietorship/ partnership/
company/ society/ others
4. Name, address & contact details of the
Promoter
5. Name, designation & contact details of the
Authorize Person
6. EM No. & Date (MSMEDA Part-II)
7. Details of any other financial assistance
granted by GOG/GOI
8. Whether any Government dues are
outstanding or not? If Yes Give details
thereof
9. Whether any court case? If Yes Give details
thereof
10. Declaration:
I hereby declare that the information, statements & other papers given
herein are to the best of my knowledge & belief, true and correct in all
particulars, incentive government resolutions and prevailing
government rules and regulations.
I also declare that I am duly authorized to sign an application and
details and documents submitted in this application.
Note: Any financial transactions / expenditure statements submitted by the unit
must be signed by the authorized signatory of the institute and certified by the
auditor/ chartered accountant, if applicable

Date: Signature of Authorized Signatory

Place: Seal of the Unit

 Annexure - 1: Application Form

Part-II: Interest Subsidy to MSME

1. Name of the Unit

2. Whether the promoter is a youth of age Yes/No.
below 35 years?
Age of Promoter/ Promoters as the time of
first disbursement of loan:
3. Whether this is the first project of the Yes/No.
Promoter?
4. Whether the promoter is woman? Yes/No.
5. Category of Unit: (please tick appropriate)

New Unit

Expansion

Modernization

Diversification

6. For the units going under Expansion

/Diversification/ Modernization:
Gross Fixed Capital Investment of Existing
___________ Rs. Lakhs
Unit
Fixed Capital Investment of Expansion /
Diversification/ Modernization ___________ Rs. Lakhs

Increase in Fixed Capital Investment ___________ %

7. Purpose of Modernization (Please tick below, as appropriate) and submit the

brief write-up for the same
To adopt new technology of a product
To adopt new technology for improvement of processes
To adopt new technology for improvement of productivity
Others, Please specify
8. Name & Address of Financial Institution
9. Loan Sanction Date:
Amount of loan sanctioned:
 Date of Installment Disbursement:
10. Date of Commercial Production
11. Unit Details:
Manufacturing Item :
Annual production Capacity (Rs. or in
units):
Investment in Plant & Machinery:
12. Details of Fixed Capital Investment for new unit/ expansion/
diversification/ modernization (Budget Estimate in details) (Rs. In lacs)
Land:
Building:
Plant & Machinery/ Equipments:
Others:
TOTAL:
13. Means of finance Rs. Lakhs Percentage
Promoter’s Contribution:
Term Loan (Name of Fin. Insti):
Internal Resources:
Deposit:
Others:
TOTAL:
14. Status of Machinery New/ Second hand/ Imported
Second hand
15. Status of GPCB approval:
Approval No. Approval Date
NOC obtained
Consent (CTE) obtained

16. Details of existing employment

Sr. Level/ Type Local Outside Share of local employment
1 Workers
2 Supervisor
3 Manager
Total

17. Details of Proposed employment

Sr. Level/ Type Local Outside Share of local employment
1 Workers
2 Supervisor
 3 Manager
Total

18. Project report, if the loan amount is more

than Rs. 1 crore, covering:
1. Project profile
2. Details of equipments & machineries,
3. Fixed capital investment
19. I hereby opt for Interest Subsidy under the scheme of (Mark tick as
appropriate)
Scheme under Industrial Policy, 2003 as a pipeline case@ □
Scheme under Industrial Policy, 2009 # □
20. Other information, if any

Date: Signature of Authorized Signatory

Place: Seal of the Unit

@ If the unit has taken first disbursement of loan on or before 26.02.2009 and
started commercial production on or before 26.02.2010.
# The unit will be eligible for interest subsidy on the loan disbursed after
26.02.2009.
Annexure - 2: Certificate from Financial Institution

This is to certify that M/s. …………………………………… has been sanctioned Rs.

…………… term loan for the project at ……………………. at the rate of __% interest
for the Project.

The unit has been disbursed total of Rs. …………………. upto ………… The first
installment of the term loan of Rs. …………. was disbursed on dt……………

The Unit had made repayment for the period dt……………….. to dt …………. as
under:

Against Term Loan Rs. ………………………

As Interest Rs. ……………………………
Total Rs. ……………………….

The interest subsidy @ 5%/6%/7% on the amount disbursed for the period from
…………… to …………. is Rs. ………………………

This is to certify that penal interest or other charges are not included in the said claim
and the enterprise pays regular installments and interest to the bank.

The enterprise is not defaulter of the bank. (In the case of defaulter, please give
default period details).

Place: Signature
Date: Branch Manager
Name of Bank

Seal of the Bank