Guidelines for Impact Monitoring & Assessment in Microfinance ...

MONITORING & ASSESSMENT IN MICROFINANCE PROGRAMMES
TOOL 2: Client Monitoring: Loan Application Form/page 3
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CREDIT REFERENCES
Supplier Credit/Loan/Lease
Amount Date: Amount paid Outstanding amount
Credit 1:
Credit 2
Credit 3
Credit 4
Other
CASH RESOURCES
Institution Account Deposit Regularity Balance
Savings: Bank1:
(describe) Bank 2:
Partner:
Home:
NGO, etc.:
Other:
Checking:
HOUSEHOLD ASSETS
DO THE MEMBERS OF YOUR HOUSEHOLD OWN ANY OF THE FOLLOWING?
Yes No Last Year Yes No Last Year
How Many Yes No How Many Yes No
Sewing machine TV Set
Gas stove Video
Equipment
Electric stove Washing
machine
Refrigerator Bicycle
Freezer Motorbike
Air Conditioner Car
Fan Other Vehicle
Radio/Cassette Utensils
Stereo
Equipment
Jewellery
Other
SCHEDULE OF ASSETS SUBJECT TO LIEN
(Owned by Applicant)
Description Serial # Condition Age Value
PURPOSE OF DRAW
The above assets are fully owned by me and I hereby consent to pledging them as Security for my Workers Bank Early
Draw Plan.
I also hereby agree to participate in any evaluation study conducted by Workers Bank for the purpose of assessing performance
of the Programme.
Signature: _______________________ ________________________________
Applicant Bank/Loan Officer