Filled Sample of

Undertaking/Declaration
 IIOVELY
Iii ROFESSIONAL INCOME DECLARATION
D)NIVERSITY FORM
(Self Attested)
'Trans{orminJ 'Educafion 'Trans{ormiYJ_J 9ndia

1. That I am a citizen of India and permanent resident of address mentioned above.

2. That my ward (S~Daughter)_ _.,\.,_-A-'--'-YY\'--"-'OJ(\"-"---'---"~""'""=-=t')_....,c_~c..•....;.V'_~-----"-----(Name of the student) bearing Candidate

ID 2.\,,\ DO o \ would like to apply for LPU based Scholarship Scheme for the session no - L\ - 2 S::::
_,L.. '.l -
'

3. That my and my family annual income from all sources is mentioned below:

•Annual Income from

Family Details Education Level Occupation
all sources (in Rs.)

Father ~e 'Bv...ol~ 8,00,000

Mother G{ovt;Sec,\-~ -~00,0C9O ...
.E
NA
E
Guardian (To be filled only if he/she
is paying the fees of the ward)
rvA .EC
0

'Total annual family Income from all sources (In Rs.) \3 ,C)O) ao o a.
C
0
'Income from salary/ pension/ rental/ business/ profession/ agriculture /any other sources.
gj
Cl>

I hereby declare that all the information either mentioned above or in enclosed documents (if any) are true and correct to the best of my :gE
knowledge and nothing has been concealed therein. I very well know the fact that If any Information Is found to be false and incorrect Cl>

than I will liable to be punished under Law in Force and any benefits received by me will be liable to be ceased.
:,

i
E

@A ?'\'Self Declare •
(Signature of P. ants/ Guardian* with date)
In case Father is not alive, then certificate from Mother/ Guardian is required
Mention relation with applicant In case of Guardian