Apply for Help | Shri Shyam Jansewa Trust

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Please fill all form fields in English (Roman letters) only.

उदाहरण: नाम → Savita Maurya | शहर → Lucknow | पता → Plot No. 58, Raipur

Step 1 — Applicant Information

The person who is applying for assistance

Who needs the assistance? *

For Myself (Self)

For a Family Member

For Another Needy Person

Applicant Personal Details

Full Name *

Father / Husband Name

Date of Birth *

Age (Years)

Gender *

Mobile Number (for OTP/Call verification) *

Email (Optional)

Address Details

Full Address (House No, Street, Area etc.) *

State *

District *

City / Block *

Village / Area

Pincode *

Occupation (Optional)

Photo & Identity Documents

Applicant's Photo *

Upload Photo (JPG, PNG)

Max 5MB

पहचान पत्र (Aadhaar/Voter/DL) *

ID अपलोड करें (PDF, JPG, PNG)

Max 5MB

Step 2 — Beneficiary Information

The person for whom assistance is needed

You have selected 'For Myself (Self)'

Applicant information will be used as beneficiary details.

Beneficiary Personal Details

Beneficiary's Full Name *

Father / Husband / Guardian Name

Date of Birth *

Age (Years) *

Gender *

Mobile Number (if available)

Relationship with Applicant *

Permanent Address *

Is the beneficiary a minor? (Below 18 years of age)

Beneficiary Photo & Identity Proof

Beneficiary's Photo *

Upload Beneficiary's Photo

Beneficiary's Identity Proof *

पहचान पत्र (Aadhaar/Birth Cert)

Step 3 — Type of Assistance

What type of assistance do you need?

Medical Assistance

Education Assistance

Food Assistance

Financial Assistance

Disability Assistance

Family Assistance

Animal / Gaushala

Disaster Relief

Other Assistance

Medical Assistance Details

Disease / Problem *

Hospital Name (Optional)

Doctor's Name (Optional)

Treatment Status *

Hospital City

Estimated Treatment Cost (₹)

Amount Already Paid (₹)

Amount Required Now (₹) *

Documents (Medical Related)

Doctor's Prescription

Medical Report

Cost Estimate

Step 4 — Problem Description

Describe your situation and requirement

Describe your problem in detail * Please write at least 50 characters.

Required Assistance Amount (₹) *

How will this amount be used? (You can select more than one)

Treatment Hospital Payment Medicine Education Fees Food Household Expenses

Step 5 — Amount & Bank Details

Bank account details of the person for whom assistance is sought

Whose bank account is this? *

Beneficiary's Own Account Guardian / Parent Account Joint Account Other Family Member Account

Bank Details

Account Holder Name *

Bank Name *

Account Number *

Account number पुनः दर्ज करें *

IFSC कोड *

Branch Name (Optional)

Account Type *

Passbook Photo / Cancelled Cheque *

Upload passbook front page or cancelled cheque

JPG, PNG, PDF (Max 5MB)

Step 6 — Declaration & Submit

Confirm final details and submit your application

Select Application Type *

🔘 ₹11 Priority Application (Voluntary Donation)

A voluntary contribution for Trust service initiatives.

🔘 Free Application (₹0)

Standard assistance application process (₹0 fee).

Important Note: The ₹11 amount is not a registration fee but a voluntary donation for the Trust. This amount is non-refundable and does not guarantee assistance. Assistance decisions are made by the Trust based on verification, eligibility and available resources.

Declaration

I declare that the information provided is true and correct. I have read and agree to the Terms & Conditions of the Trust. I understand that the ₹11 amount is a voluntary donation and is non-refundable. If I am applying on behalf of another person, I have their full consent.

Date

City / Place *

Shri Shyam Jansewa Trust

Application Form for Assistance