INCOME DECLARATION FORM

1.

2.

3.

(a)
(b)
(c)
4.
5.

Name of the Student:

(i) Name of the Father
(ii) Whether Employed
(iii) if employed, Designation
(iv) Salary per month
(i) Name of the Mother
(ii) Whether employed
(iii) if employed, Designation
(iv) Approx 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
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)

Regd.No.

(iv) Vehicle registered on whose name

6.

(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

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7
8.
9.

(v) Any other type of house

(i) Whether living in own house or rented house
(ii) if rented, mention rent amount
Telephone/Mobile Number
Total Family income from all sources

I here by declare that the above information given by me is true and 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

Token Number of student: _____________

Address: H.No: ______________
Course: ____________________
Course Year: ______
Village & Mandal: ____________
College:
City & District: ______________
_________________________________________________________
College District: ____________
Mobile No: __________
Mobile No: __________

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