\, AFFIDAVIT 4___ mapa + siv my Slo, Wio, Sri_MADIKLs JOCAWA ‘aged about__\Y__ years having an occupation of __KaMaRAZupETa —ssidentof__ Wn 1 D.No LocaligiLandimark __MCAMARAT PETA Village /towm GuokauaRAan. Mandal FAST GeapAvA District _ sneer Pincode do hereby solemnly affirm and state on oath as follows. | am the deponent herein as such [am well acquainted wit the facts ofthis affidavit. I submit that Iam the resident of above address, 1am doing FARMER (Profession) and geting Rs.__ 70, ano inRupees SPVECTY “THAVSAND Rupees only per annum from all sources mentioned below excep the above sei income. Hbelongio__CADAV A Caste, which comes under SCISTIBCi/Others “Te income certificate is necessary for my Son/ Daughter Malis VEERA VEWkaTs SATA Men’) Whois studying VISKOU Ghicg.6 of puctmvac 1GhteyaudRO) —_fse Reiner acuelfe !she required income certificate for getting scholarship / Fee reimbursement, hence I am giving this affidavit along with income declaration, INCOME DECLARATION (As pet G.O., RT No.1307, Rev., (Ser.II) Dept., and Dt.13.9.2010) 1 Name ofthe student inant. 1g @Ra veakara aT a Muay, 2 [Date of Birth 3|@ Name of the Father (@) Whether Employed (Gi employed designation, if uot ether profession 6) Salary per month 4] Name of the Mother Gi) Whether Employed (Gi Iremployed, designation, ifnct other profession Gv) Salary per month 5 | Agricultural holding of the parents mention extent @ In dhename of Father Gi) In thename of Mother (@) Crops grown in land(&) Whether Dry or wetland 1 Annual income from agricultural land 6 | Business mention the trade /name of business Income > _ derived from the venture 7 |@ Number of vehicles ovmed by the family Gi) Whether used for personel / private use only (ii) Mention type of vehicles (too wheeler / three wheeler/four wheeler): Rega No. Gv) Vehicle registered on whose name 8 |@ Type of house mention Whether RCC / thatched / Tiled roofed Gi) Mentioned, whether Indiramma House Gi) Cost construction of House Civ) Whether constructed with loan, ifs amount and bank Branch (0) Any other type of house 9 |) Whether living in own house or rented house QevTep Mona. (i) If rented, mention rent amount 10] Telephone/Mobile Number 11 | Total family income fram all sources 28,6%0/- 12] Ration Card Number Usp OUITATIOORAW 13] Aadhar Card Number ——Wi24_ Gos voy = 14] Email Salamone) 1n6) oublook. Gos. o | shall be liable for penal action both civil and criminal, ifthe above facts are false in future besides recovery of the scholarship ‘ih penal interest under the revenue recovery act. Therefore, I request the concemed revenue authorities may be pleased to accep this affidavit and issue income certificate to my son/daughter o amen for scholarship / fee reimbursement purpose maiki-veska WGokaia Bat¥a Mody The above facts are truc and correct to the best of my knowledge and belief. vavev-Batha von ee Abe Name & signetice gf the sadyfie Name & Signature of the Part DEPONENT Ls 12 -201y Date: Place: KavaraTope TA Solemnly aff and signed before me ston Anested by Signature ofthe Notwy