Print the below income declaration on the Non-Judicial Stamp Paper (Rs.

10/-)

INCOME DECLARATION FORM Name of the Student:- MAKKENA.NAGESWARA RAO

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
M.VENKATESWARLU
AGRICULTURE LABOUR

4.

NO NO
M.SUJATHA

5.

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

NO NO NO NO NO NO

HOUSE WIFE NO NO NO NO NO NO NO NO

6.

RCC THATCHED
NO NO NO NO

3.

(a) (b) (c)

7.

(i) Whether living in own house or rented house (ii) if rented, mention rent amount Telephone / Mobile Number

OWN HOUSE
NO

9618506939

9. Total Family income from all sources. RS:50,000/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 (2013-14): Course: B.TECH (CSE) Course Year: 2ND YEAR College: QIS COLLEGE OF ENGINEERING & TECHNOLOGY, VENGAMUKKAPALEM College District: ONGOLE, PRAKASAM Name & Signature of the Parent Address: H.No.: 1-101, BHEEMAVARAM VIL Village & Mandal: MUNDLAMURU City & District: PRAKASAM Mobile No: 9618506939