Print the below income declaration on the

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

INCOME DECLARATION FORM

Name of the Student: YALLA JOSEPH WESLEY
1.

2.

3.

(a)
(b)
(c)

(i) Name of the Father

YEDUKONDALU

4.

(ii) Whether Employed

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

NO
FARMER

5.

(i) Name of the Mother

NIRMALA

(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

NO
HOUSEWIFE

NO

7.

Whether Dry or Wet land

Annual
Income
from
Agricultural Land

NO
NO

NO

6.

NO
NO
NO
NO

Business mention the trade/name of

business
Income derived from the venture
(i) No. of Vehicles owned by the Family

NO

(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

NO

(iv) Whether Constructed with loan, if

so amount and Bank Branch
(v) Any other type of house

NO

(i) Whether living in own house or

rented house
(ii) if rented, mention rent amount
Telephone / Mobile Number

RENT

NO
NO

Regd. No.
NO
RCC
NO
NO

NO

500
9704510395

9.
Total Family income from all sources.
36000
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
ePASS Application ID (2015-16):____________
Course: B-TECH Course Year:4TH
College: B V C ENGG ODALAREVU
College District:EASTGODAVARI

Name & Signature of the Parent

Address: H.No.:_2-5-87/1
Village & Mandal:AMALAPURAM
City & District: EASTGODAVARI
Mobile No:9704510395