Print the below income declaration on the

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

INCOME DECLARATION FORMName of the Student1. (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 House3. 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 Land8 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 ParentePASS Application ID (2012-13):____________ Address: H.No.:____________Course: ________ Course Year:_ Village & Mandal:___________College: ____________________________________ ___________ City & District: _____________College District:______________ Mobile No:_________Mobile No:__________