HOUSEHOLD INCOME DECLARATION FORM

For Parents/Guardians without e-B or e-BE Form/Pay Slip/Income Statement

or Self Employment (To be completed by Parents/Guardians)

TO:

MALAYSIAN RUBBER EXPORT PROMOTION COUNCIL

BLOCK 2A, LEVEL 13A-1, PLAZA SENTRAL,
JALAN STESEN SENTRAL 5, 50470 KUALA LUMPUR

1.
DETAILS OF STUDENT
FULL NAME (AS IN NRIC)
NRIC
2. DETAILS OF FATHER/GUARDIAN

3. DETAILS OF MOTHER/GUARDIAN

NAME : ________________________________

NAME : ________________________________

_______________________________________

______________________________________

NRIC : __________________________________

NRIC : _________________________________

RELATIONSHIP : __________________________

RELATIONSHIP : _________________________

OCCUPATION : ___________________________

OCCUPATION : __________________________

MONTHLY INCOME : RM___________________

MONTHLY INCOME : RM__________________

I HEREBY DECLARE THAT ALL INFORMATION IN I HEREBY DECLARE THAT ALL INFORMATION IN
THIS FORM ARE ACCURATE AND TRUE.
THIS FORM ARE ACCURATE AND TRUE.

__________________________

__________________________

(SIGNATORY)

(SIGNATORY)

DATE :

DATE :

4. VERIFICATION

_________________________________
(SIGNATORY AND OFFICIAL STAMPING)
NAME :
POSITION :
DATE :

The VERIFICATION can only be made by a

Wakil Rakyat, Government Official (Group
A), Sessions Court Judge, Magistrate, Legal
Practitioner, Commissioner of Oaths, Public
School Principal, Police Officer (ranked
Assistant Superintendent of Police and
above), Army Officer (ranked Captain and
above), Village Head, Imam, Penggawa,
Tuai Rumah, Head of Clan or certified
Mukim.