INCOME DECLARATION FORM - Centre for Good Governance



Print the below income declaration on the

Non-Judicial Stamp Paper (Rs. 10/-)

INCOME DECLARATION FORM

|Name of the Student |

|1. |(i) Name of the Father | | |4. |Business mention the trade/name of business | | |

| |(ii) Whether Employed | | | |Income derived from the venture | | |

| |(iii) if employed, Designation | | |5. |(i) No. of Vehicles owned by the Family | | |

| |(iv) Salary per month | | | |(ii) Whether used for personal/private use only | | |

|2. |(i) Name of the Mother | | | |(iii) Mention type of vehicles (two wheeler/ | |Regd. No. |

| | | | | |three wheeler/four wheeler) | | |

| |(ii) Whether Employed | | | |(iv) Vehicle registered on whose name | | |

| |(iii) if employed, Designation | | |6. |(i) Type of House: Mention whether RCC, | | |

| | | | | |thatched/Tiled roofed | | |

| |(iv) Salary per month | | | |(ii) Mention whether Indiramma House | | |

|3. |Agricultural holding of the | | | |(iii) Cost of Construction of House | | |

| |parents mention extent | | | | | | |

| |(i) In the name of the Father | | | |(iv) Whether Constructed with loan, if so amount| | |

| | | | | |and Bank Branch | | |

| |(ii) In the name of the Mother | | | |(v) Any other type of house | | |

|(a) |Crops Grown in land | | |7. |(i) Whether living in own house or rented house | | |

|(b) |Whether Dry or Wet land | | | |(ii) if rented, mention rent amount | | |

|(c) |Annual Income from Agricultural | | |8 |Telephone / Mobile Number | | |

| |Land | | | | | | |

| | | | |9. |Total Family income from all sources. | | |

I hereby declare that the above information given is true & correct. I will be held liable for any wrong information given which shall include cancellation of scholarship, recovery of amounts paid already if any besides criminal action.

Name & Signature of the Student Name & Signature of the Parent

ePASS Application ID (2015-16):____________ Address: H.No.:____________

Course: ________ Course Year:_ Village & Mandal:___________

College: ____________________________________ ___________ City & District: _____________

College District:______________ Mobile No:_________

Mobile No:__________

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