Application Form for assistance under Special Credit Linked Capital Subsidy
Scheme (SCLCSS) for SC/ST Micro & Small Enterprises
(To be submitted in triplicate, Photocopies may be used)
1. Name of the firm/company ... ... ... ... ... ... .. . .. . ....... ... ... ...... ... ... .. . ... ... ... ... ... ... ...
[Link] (Proprietary concern, partnership firm, Pvt. Ltd. Co., Public Ltd. Co., Coop. Societies)
3. Name(s) of sole proprietor/partners/directors... ... ...... ... ... .. . .... ... .. . .. . .... ... .. ......
4. Category of borrower (SC/ST) ...... ... ... ... ......
5. Registered Office Address ... ... ... ... ... ... .... ... .. ... ... ......... ...... .. . ... ... ... ... ... ...... ...
Pin... ............. ... ............ ... .. . .
Phone No... ... ... ...... ... .. .... ... ...... ... .. . ... ... .. .... ... . Fax... ... ... ... ..... . ....... ... ... ....
Email.... ... ... ... ...... ... ... ... .. . .. . ... .. . ... .. . ...... ......... ... .. .
6. Factory
Address.. . .... ... ... ... ... ... ... ... .. . ... ... ... .. . ... .. . ..... . ... .. . ... ... ... ... ... ... ....... Pin... ... ...
Phone... ... ... ... ... ... ... ... ... ... ... ...... ... ... ... ... ... ... ......
Fax... ... ... ... ... .... ... ... .. . ... ... ... .
Email... ... ... ... ... ... ... ...... .... ......
7. Location of factory - Backward/ Non backward area/North Est Region... .... .... .. ...
8. Date of incorporation/commencement of production .. . ......... ... ..... . ... ..... . ... ...
9. Product(s)/Subsector...... ... ... ... ... .. . .. . .. . .... ... ... ... .. . ... ... .. . .. . .... .. ... ... .... .. ...
10. Installed capacity... .... ... ... ...... ... .. .. ... .. ... ... ... ... ... .. . ... ... .. .. ... .. ... ...... ...
11. Past Performance (for last three years on the basis of audited balance sheets — in respect of
existing units. In respect of new units projections for next three years may be given).
a. Financial position
(Rs. In lakh)
Financial Year (Y- Financial Year Financial Year (Y-
1) (Y-2) 3)
I Net block
II Current assets
111 Current liabilities
IV Term Loan
V Share Capital
VI Reserve & Surplus (less accumulated
losses)
VII Net worth(V+VI)
b. Working Results
(Rs. In lakh)
Financial Year (Y- Financial Year Financial Year (Y-
1) (Y-2) 3)
I Total Sales
II Gross profit (Before interest &
depreciation)
Ill Depreciation
IV Interest
V Operating Profit
VI Net Profit (after tax)
12. Total cost of scheme (as approved by Bank/Fl) (Rs. in lakh)
13. Total Sources of funding (as approved by Bank/Fl) (Rs. in lakh) Term Loan............. .... .....
......... ...... ..................... .... .
Add share capital ......... ........ ............................... ...... .
Internal accruals. ,........ . ... ... ..... . .... .. .. .... .... .. ... .. ....... .. .
Capital Subsidy .... .................... ............. ................... .
14. Time frame for completion of the project............................
15. Incremental benefits from implementation of the project (indicate in terms of capacity
utilization, increased sales, exports, reduction in cost of production, increase in productivity,
quality upgradation, attainment of pollution standards - give quantitative results).
16. List of eligible plant and machinery along with their detailed specifications, rates, quantities,
and total value for which subsidy under SCISS is claimed.
DECLARATION
I/ Wee, hereby declare that the information given above, and the statement and other papers
enclosed are to the best of our knowledge and belief are true and correct.
Place: Signature(s)
Date:
Name and designation Seal of the company
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