INCOME DECLARATION FORM Name of the Student

1. (i) Name of the Father (ii) Whether Employed (iii) if employed, Designation (iv) Salary per month 2. (i) Name of the Mother (ii) Whether Employed (iii) if employed, Designation (iv) Salary per month Agricultural holding of the parents mention extent (i) In the name of the Father (ii) In the name of the Mother Crops Grown in land Whether Dry or Wet land Annual Income from Agricultural Land 4. Business mention the trade/name of business Income derived from the venture (i) No. of Vehicles owned by the Family (ii) Whether used for personal/private use only (iii) Mention type of vehicles (two wheeler/ three wheeler/four wheeler) (iv) Vehicle registered on whose name (i) Type of House: Mention whether RCC, thatched/Tiled roofed (ii) Mention whether Indiramma House (iii) Cost of Construction of House (iv) Whether Constructed with loan, if so amount and Bank Branch (v) Any other type of house 7. (i) Whether living in own house or rented house (ii) if rented, mention rent amount Telephone / Mobile Number Total Family income from all sources.

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Regd. No.

6.

3.

(a) (b) (c)

8 9.

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 ePASS Application ID (2011-12):____________ Course: ________ Course Year:_ College: ____________________________________ College District:______________ Mobile No:__________ ___________ Name & Signature of the Parent Address: H.No.:____________ Village & Mandal:___________ City & District: _____________ Mobile No:_________