Pradhan Mantri TB Mukt Bharat Abhiyaan

Ni-kshay Mitra Enrolment Form

Community Support to Tuberculosis Patients (Government of India Initiative)

1. Basic Details of Ni-kshay Mitra

Name of Mitra / Organization

Mobile Number

Email ID

Mailing Address

State

District (Geographical Location)

2. Commitment & Type of Support

Nature of Support to be Provided

Minimum Duration of Support

6 Months (Minimum)

1 Year

2 Years

3 Years

No. of Patients

COMMITTED SUPPORT PRICING

Rate of support is ₹1,000 per patient per month.

Calculation: 1 Patient(s) × 12 Month(s) × ₹1,000

Total Commitment Amount₹12,000

3. Geographical Area of Support

Support Level

4. Declaration & Privacy Undertaking

I/We hereby declare that the details provided above are true and correct. I/We commit to providing continuous, quality services to the supported TB beneficiaries for the specified duration. I/We explicitly undertake that I/We shall not use beneficiary data or diagnostic information for any purpose outside the official 'Community Support to TB Patients - Ni-kshay Mitra' framework, nor disclose patient identities to any external identity or unauthorized organization.

I / We accept the above official declaration & privacy undertaking.

5. Dedicated Fund Transfer Protocol

For processing corporate allocations or community fund transfers directly to patient-centric support structures (Sahayog Kosh framework), complete bank metrics are outlined below:

Account Name:Ni-kshay Mitra Support Fund

Bank / Branch:State Bank of India, Imphal Secretariat

Account Number:40910293847

IFSC Code:SBIN0004562

Upload Payment Receipt / Proof

Click to upload or drag & drop

Supports JPEG, PNG or PDF (max 5MB)

SCAN TO PAY VIA UPI

Amount: ₹12,000UPI ID: nikshaymitra@sbi