Components of Project Report

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Appendix – A

Application form for Incentives under Para 4.9 (A) (B) and (C) of Package Scheme of
Incentives - 2013

1 Application Number (For Office Use)


2 Date of Receipt (For Office Use)
3 Name of the Applicant Unit

4 Factory address of the unit

5 EC NO (PSI-2013) & Date

6 Capital Cost of the Project (Rs. in Lacs) As per


FCI
EC
Land

Building
Plant & M/c.
Other Assets
Total
7 Expenditure incurred on Technology
upgradation alongwith appraisal of project
under Technology upgradation by
Chartered Engineer (appendix – II/A)
8 Expenditure incurred on quality
certification alongwith copies of valid
quality certificates or quality marks
(appendix – II/B)
9 Expenditure incurred for cleaner production
alongwith certification from
MPCB/CPCB/GoI organizations.
(appendix – II/C)
10 Expenditure incurred on Patent registration
(National/International) alongwith copy of
Patent registration from competent
authority and certified by CA
(appendix – II/D)
11 Expenditure incurred on cost of water audit
alongwith copy of Audit document by the
empanelled agency(appendix – II/E)
12 Expenditure incurred on cost of energy
audit alongwith copy of audit document by
the empanelled agency (appendix – II/E)
13 Capital expenditure incurred under
measures to conserve/ recycle water
alongwith certificate from
empanelled agency (appendix – II/F)
14 Capital expenditure incurred under
improving energy efficiency
alongwith certificate from empanelled
agency (appendix – II/F)
15 Expenditure incurred on Credit Rating
alongwith copy of Credit Rating from
competent authority and certified by
CA (appendix – II/G)
16 Auditors certificate for power tariff
subsidy alongwith details of electricity
bills of respective year (appendix – II/H)
17 Certificate from Term lending Bank/
Financial Institute about interest paid on
Term loan alongwith Auditors certificate
of interest paid in respective year.
(appendix – II/I)

1. Certified that no claim for incentives has been sanctioned or disbursed to the
project / unit aforesaid and that this is the first application in regard to the project /
unit aforesaid.

2. Certified that the information / statement contained in this application are true to
the best of my / our knowledge and belief.

3. Declared that no Government enquiry has been instituted against the applicant unit
and / or any of its Proprietor / Partner(s)/ Director(s) of this applicant unit for any
economic offence.
4. We hereby agree to abide by the terms and conditions of the claim sanction to be
issued. In pursuance of the above application for incentives under para 4.9 (A) (B)
and (C), para 4.8 and para 4.5 of Package Scheme of Incentives - 2013.

5. We hereby agree that the Certificate of Entitlement / claim sanction letter issued
on the basis of the above statements made and information furnished either
alongwith this application or hereafter in connection with the above matter is
liable to be canceled ab-initio or rendered invalid or withdrawn if any of the
statements and / or information is / are found to incorrect / untrue. All the
momentary benefits already availed of on the basis of the Claim Sanction so
cancelled shall be recoverable as Government dues forthwith alongwith simple
interest at @ 10 % per annum or at such other higher rate as may be fixed by the
Implementing Agency from time to time and no further benefits will be available
to the project unit for which the above application is made.

Signature of the applicant Proprietor / Partner


/ Director / Trustee
Place:

Date:

(This application shall be signed only by any one of the persons indicated above with
appropriate rubber stamps of the applicant and designation of the signatory)

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