Income Declaration Form

Print the below income declaration on the

Non-Judicial Stamp Paper (Rs. 10/-)

INCOME DECLARATION FORM

Name of the Student
1. / (i) Name of the Father / 4. / Business mention the trade/name of business
(ii) Whether Employed / Income derived from the venture
(iii) if employed, Designation / 5. / (i) No. of Vehicles owned by the Family
(iv) Salary per month / (ii) Whether used for personal/private use only
2. / (i) Name of the Mother / (iii) Mention type of vehicles (two wheeler/ three wheeler/four wheeler) / Regd. No.
(ii) Whether Employed / (iv) Vehicle registered on whose name
(iii) if employed, Designation / 6. / (i) Type of House: Mention whether RCC, thatched/Tiled roofed
(iv) Salary per month / (ii) Mention whether Indiramma House
3. / Agricultural holding of the parents mention extent / (iii) Cost of Construction of House
(i) In the name of the Father / (iv) Whether Constructed with loan, if so amount and Bank Branch
(ii) In the name of the Mother / (v) Any other type of house
(a) / Crops Grown in land / 7. / (i) Whether living in own house or rented house
(b) / Whether Dry or Wet land / (ii) if rented, mention rent amount
(c) / Annual Income from Agricultural Land / 8 / 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 Name & Signature of the Parent

ePASS Application ID (2013-14):______Address: H.No.:______

Course: ______Course Year:_ Village & Mandal:______

College: ______City & District: ______

College District:______Mobile No:______

Mobile No:______