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.

3.

(a)
(b)
(c)

4.

5.

(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

6.

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

Regd. No.

(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

9.
Total Family income from all sources.
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 (2014-15):____________
Course: ________ Course Year:_
College: ____________________________________
College District:______________
Mobile No:__________

___________

Name & Signature of the Parent

Address: H.No.:____________
Village & Mandal:___________
City & District: _____________
Mobile No:_________