INCOME DECLARATION FORM Name of the &t dent

+i, Name of the Father +ii, -hether Em$loyed +iii, if em$loyed% Designation +iv, &alary $er month 2" +i, Name of the Mother +ii, -hether Em$loyed +iii, if em$loyed% Designation +iv, &alary $er month Agric lt ral holding of the $arents mention e7tent +i, In the name of the Father +ii, In the name of the Mother Cro$s 9ro#n in land -hether Dry or -et land Ann al Income from Agric lt ral Land

'AATLA (EN'ATA &)RE&*

'"(EN'TE&-RL) FARAM 1" No No T*IRA3T*MMA No 4" No No No No No :" No No ; No +ii, -hether sed for $ersonal0$rivate se only +iii, Mention ty$e of vehicles +t#o #heeler0 three #heeler0fo r #heeler, +iv, (ehicle registered on #hose name +i, Ty$e of *o se5 Mention #hether RCC% thatched0Tiled roofed +ii, Mention #hether Indiramma *o se +iii, Cost of Constr ction of *o se +iv, -hether Constr cted #ith loan% if so amo nt and /an8 /ranch +v, Any other ty$e of ho se +i, -hether living in o#n ho se or rented ho se +ii, if rented% mention rent amo nt Tele$hone 0 Mobile N mber No ." / siness mention the trade0name of b siness Income derived from the vent re +i, No" of (ehicles o#ned by the Family No"

No
No

(egd)No No ()""
No No No No

6"

+a, +b, +c,

*+n) ,ouse No -./2/0-...

<" Total Family income from all so rces" .0000)(s I hereby declare that the above information given is tr e ! correct" I #ill be held liable for any #rong information given #hich shall incl de cancellation of scholarshi$% recovery of amo nts $aid already if any besides criminal action"

Name & Signature of the student ePASS Application Id (2012-13) "ollege "ollege $istrict Pra%asam &o'ile No

Name & Signature of the parent !illage & "it# & $istrict Pra%asam &o'ile No