Government of Kerala

Finance Department
Application for Education Loan Repayment Support Scheme

Student Registration Number. : 3147280105 Date of Submission : 2017-10-22

Personal Details

Type Of Student : Normal Student

Student Name : jikku thomas
Gender : M
Date of Birth : 12/05/1988
Secondary Board Exam Roll Number(10th Board : 314728
Examination Roll No.) *
Year of Passing 10thclass * : 2005
Board in which 10thclass Passed * : Kerala Board
House Number : 300
House Name : NEERUVELIL HOUSE
Street : KANJIRAPPALLY
Area/Locality : (U)rban
Post office : PANACHEPPALLY PO
Taluk : KANJIRAPPALLY
Pin Code : 686518
District : Kottayam
Mobile Number : 9446305535
Email Address : jikku.thomas@yahoo.com
Aadhaar Number : 212927578384
IT PAN Card Number : BBMPT8105M
Category : GEN
Name of Father/Mother/Guardian/Spouse : THOMAS DOMINIC

Course Details

Seat Type : merit

Course Type : POST GRADUATE
Name of Professional Course : M TECH - Computer Science and Engineering
State of Institution/College/University : Tamil Nadu
District of Institution/College/University : Salem
Name of Institution/College/University : Paavai Engineering College
Affiliation/Accreditation of the Institution/College/ : ANNA UNIVERSITY
University
Course Completed : Yes
Period of Course : 2012-2014
Date of Commencement of Course : 02/07/2012
Date of Course Completion : 20/06/2014
Due Date for Commencement of Repayment : 20/06/2015

IT Services:National Informatics Center(NIC),Kerala Page 1 Date:22/10/17

Loan Details

Bank Type from which loan availed : KERALA GRAMIN BANK

Bank State : Kerala
Bank District : Kottayam
Branch Name : KANJIRAPPALLY
IFSC Code : KLGB0040546
Account Number : 54615316756313
Date of Loan Sanctioned : 20/05/2013
Amount of Loan Sanctioned (in Rupees) : 157000
Amount of Loan Disbursed (in Rupees) : 157000
Amount of Loan Outstanding (in Rupees) : 187312
Amount Repaid : 25600
Area : (U)rban

Income and Other Details

Is Student Employed : No
Family Annual Income (in Rupees) : 210000
Income Certificate Number : 27754656
Income certificate Date : 25/09/2017
Relief availed/claimed under other scheme, if any : No
other than Central/State Interest Subsidy Scheme
Is NPA : No

IT Services:National Informatics Center(NIC),Kerala Page 2 Date:22/10/17

 Declaration
I/We declare that I/We am/are eligible for repayment support under the said repayment support scheme and
hereby request the Bank to process my/our application to extend the benefit under the said Scheme to me/us. I/We
declare that the information supplied above, is correct and that this application will form the basis of claiming repayment
support on my/our Education loan from the State Government under the said scheme. I/We shall inform the Bank
immediately in case of any change in the above details and information given in this application form. I/We agree to
provide any further information and /or documents required and demanded by the bank/Government. I/We hereby offer
my/our consent for disclosure of information relating to me/us & any of the facilities proposed by me/us to regulators i/e.
Nodal agency appointed under the scheme by State Government.

I/we declare that my share of contribution will be remitted on demand by the bank.

Signature of Co-Applicant Signature of Applicant

(In the case of expired borrower student)

Date:

Place:

IT Services:National Informatics Center(NIC),Kerala Page 3 Date:22/10/17

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