INCOME DECLARATION FORM (SELF)

(As per GO RT.No.1307 dated 13-09-2010) Yes

Name of the Student VUTUKURU
: KRISHNA PADMINI
1. i) Name of the Father / Mother : SRINIVASA RAO
ii) Whether employed : Private Employee.
iii) If employed Designation : Private Employee.
iv) Salary per month : Rs.90,000/- p.a.
2. i) Name of the Mother : MADHAVI LATHA
ii) Whether employed : -NO-
iii) If employed Designation : -NO-
iv) Approx Salary per month : -NO-
3. Agricultural holding of the parents mention : ---NO---
extent
i) In the name of the father : ---NO---
ii) In the name of the mother : ---NO---
(a) Crops Grown in land ---NO---
(b) (b) Whether dry or wetland : ---NO---
(c) Annual income from agricultural land : ---NO---
4. Business mention the trade/name of business : ---NO---
Income derived from the venture : ---NO---
5. i) No. of vehicles owned by the family : ---NO---
ii) Whether used for personal/ private use only :
iii) Mention type of vehicles (two wheeler/3 : ---NO---
wheeler /4 wheeler)
iv) Vehicle regd. on whom name : ---NO---
6. i) Type of house: Mention whether RCC/ : RCC house.
thatched/Tiled roofed
ii) Mention whether Indiramma house : ---No ---
iii) Cost of the construction of house : ---No---
iv) Whether constructed with loan, if so : ---No---
amount
and Bank branch
7. i) Whether living in own or rented house : Rented house.
ii) If rented mention rent amount : ---Nil---
8. Telephone/Mobile No. : 7075909694
9. Total family income from all sources : Rs.90,000/- per annum.
I, declare that the above information given is true and correct to the best of my knowledge and belief. If it is
proved false I will be liable to prosecution as per law, which includes cancellation of scholarship, recovery of the amounts
paid already.

Name & Signature of the student Name & Signature of the student parent
Course : B.Tech (C.S.E) 4th Year, Vutukuru Srinivasa Rao, S/o. Narasimha Rao,
College : SBIT, Khammam, R/o.H.No.4-1-55, Rotary Nagar, Khammam City,
Khammam Town & District. Khammam District.

INCOME DECLARATION FORM

Name of the Student :
i) Name of the Father :
ii) Whether employed : No
iii) If employed Designation : -
iv) Salary per month : -
2. i) Name of the Mother :
ii) Whether employed : No
iii) If employed Designation : -
iv) Approx Salary per month : -
3. Agricultural holding of the parents mention extent :
i) In the name of the father : Ac.3-00
ii) In the name of the mother : -
(a) Crops Grown in land -
(b) (b) Whether dry or wetland : -
(c) Annual income from agricultural land : Rs.95,000/-
4. Business mention the trade/name of business : --
Income derived from the venture : --
5. i) No. of vehicles owned by the family : -
ii) Whether used for personal/ private use only : -
iii) Mention type of vehicles (two wheeler/3 wheeler : -
/4 wheeler)
iv) Vehicle regd. on whom name : -
6. i) Type of house: Mention whether : RCC house
RCC/thatched/Tiled roofed
ii) Mention whether Indiramma house : Yes
iii) Cost of the construction of house : Rs.30,000/-
iv) Whether constructed with loan, if so amount and : -
Bank branch
7. i) Whether living in own or rented house : Own house
ii) If rented mention rent amount : -
8. Telephone/Mobile No. :
9. Total family income from all sources : 95,000/- p.a.
I, declare that the above information given is true and correct to the best of my knowledge and belief. If it is proved false I
will be liable to prosecution as per law, which includes cancellation of scholarship, recovery of the amounts paid already.

Name & Signature of the student Name & Signature of the student parent
Course : nd year, B.Sc (Elc) ,
College: SR & BGNR Degree College, Khammam. Khammam District .
ID No.