SITARAM JINDAL FOUNDATION, JINDAL NAGAR, TUMKUR ROAD, BANGALORE 560073 (Formerly known as S.J.

JINDAL TRUST)

QUESTIONNAIRE
(Please read notes on page 2 and send this questionnaire fully filled along with all annexures given) 1 Name of organisation: Address 2. Constitution : (i) Institution (ii) Society (iii) Trust 3. No. of members in the Trust/ Society (enclose list)
b) In case of Hospitals run by you

(tick applicable)

Telephone no. E mail address 4 Give brief details of your activities during the previous financial year:
a) In case of Schools run by you

i) Whether Govt. Aided/Private ii) Approved by Govt.(Yes/No) iii) Number of classes/courses (enclose details) iv) Students strength(furnish classwise details) v) Fee collected from students(course wise- p.a.) vi) No. of students getting free education vii) No. of students getting fee concession

i) Number of beds ii) No. of Patients in OPD per day iii) No. of patients in IPD iv) Getting any free medicines from Govt. v) No of patients getting free treatment p.a. vi) No of patients getting concessional treatment p.a. vii) Please attach separately details of charges for consultation/ Lab tests/ X-Ray etc. No. of beneficiaries getting free services concession Details of charges collected

c) Other activities:
Activity

1) 2) 3) 4) 5) Total Please furnish schedule of charges collected for each of the above activities. 5 Details of any recurring / non recurring grant or assistance being received from Central / State Government or local body / Private Trust/Institutions. 6 Details of financial assistance, if any received from us? 7 Donation is being requested for: (tick applicable) (a) Recurring expenses (b) Non-recurring/construction/purchase of asset (c) Expenses required in kind if any Amount(Rs) (pl give details separately) (pl give details separately)

8 Items if donation is required for proposed Construction please state: a) Whether land has been acquired b) If yes to (a), is in the name of the Institution(pl attach proof.) c) Total cost of the project d) Whether building plans have been approved by Govt. authority? If so provide a copy of the approved plan e) Estimated cost of construction f) Amount collected so far for construction g) Amount spent on construction till date h) Date of commencement of construction i) Probable date of completion of project Please give justification for construction

Yes/ No / Not applicable Yes/ No / Not applicable

(tick applicable)

PTO

2 9 If donation is required for purchase of equipment etc. please state: a) Equipments /Furniture etc., proposed to be purchased b) Estimated cost (Please furnish latest proforma invoice) c) Amount collected so far for purchase of above Please give justification for purchase of above . 10 Name and Address of persons acquainted with the Institution/society/Trust a Local authority b Two prominent persons (i) (ii) Shri/Smt: Shri/Smt: Shri/Smt:

Valid upto 11 Exemption available to you under Income tax Act (enclose copy of certificate) In case of exemption u/s 35AC, please furnish the following details i) Amount sanctioned for the project (approved project cost) ii) Indicate the total amount of donation collected so far 12 Other papers / statements to be enclosed a) Brief history of the Institution / Society and its objects and activities b) Latest Annual Report of Activities c) Copy of Memorandum of Association/Rules/Trust Deed and also copy of the Registration certificate. d) Name and address of the Trustees/important Office bearers. e) Audited Annual Accounts together with schedule of fixed assets and other schedules if any. Consolidated audited statement of accounts (if you have more than one unit) with Auditor's reports for the previous 3 years to be enclosed. 80G 35(1)(ii)(iii) 35AC (tick applicable)

PLACE : DATE :

SIGNATURE OF THE AUTHORISED SIGNATORY WITH SEAL OF THE ORGANISATION

NOTE : 1 Application furnished without required enclosures/or with incomplete information is liable to be rejected. 2 It may be noted that this Questionnaire is sent to seek information to consider your appeal and it should not be

construed as an offer or an obligation on the part of the Foundation to contribute to your Organisation. The Foundation reserves its right to grant or to reject the application for donation without assigning any reason. 3 All columns to be filled in brief as per this Questionnaire and copy of the certificate /documents to be enclosed with additional information, if any.
4 Kindly return the duly filled form within 30 days, failing which the matter may be closed without any reminder.