INCOME DECLARATION FORM

Name of the Student: BUKYA SAI KUMAR

1.

(i) Name of the Father

VENKATAIAH (LATE)

(ii) Whether Employed

(iii)
if
employed,
Designation
(iv) Salary per month
2.

3.

(a)
(b)
(c)

(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

4.

5.

SAROJANA

DAILY WAGE
LABOUR

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

OWN
7729931209

9.
Total Family income from all sources.
80,0000
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: B. SAI KUMAR
ePASS Application ID (2014-15: 201404487066
Course: MECHANICAL Course Year: II
College: VAAGESWARI COLLEGE OF ENGINEERING
College District: KARIMNAGAR
Mobile No: 7729931209

Name & Signature of the Parent: SAROJANA

Address: H.No.:13-39/A
Village & Mandal: HUSNABAD
City & District: KARIMNAGAR
Mobile No: 9951000587