Rs.

20
6.20 TWENTY
RUPEES
INDIA
INDIA NON JUDICIAL
Tran Id: 231107185453490746
TELANGANA zA
KARAVINDER352116
LICÉNSED STAMP VENDOR
Date: 07 NOV 2023, 06:56 PM Lic. No. 15-25-00 1/2007
Purchased By: Ren.No. 15-25-020/2022
SANTOSH
Slo RAMESH Plot No .02 Manchirevula X
R/o R.R. DIST Road Gandipet (M), R.R,
For Whom District,
Ph 9603838098
SELF &OTHERS INCOME DECLARATION FORM
Name of the Student: DevaxupPula Saira
() Name of the Father
1. |Devorupfule 4. Business mentions the trade/name ofbusiness
() Whether Employed NO Income derived from the venture
(iii) if employed, Designation 5. () No. of Vehicles owned by the family
(iv) SalaryY per month (ii) whether used for personal/private use only Personal
2. pevaruPpula (iii) Mention ed type of Vehicles (two
() Name of the Mother
Latha
NO
wheeler/three wheeler and four wheeler) 3ohecle
() Whether employed (iv) Vehicle registered on whose name
6 ) Type of house: Mentioned whether RCC, tathe
(ii) if employed Designation Thatched/Tiled roofed RCC
(iv) Salary per month (ii) Mentioned whether Indiramma house
Agriculturalholding of the
3.
parents mention extent No (iii) Cost or Construction of House
(iv) whether Constructed with loan, ifso amount
(i) In the name of the Father and Bank Branch
(i) In the name of the mother (v) Any other type of house
(a) Crops growrfin land 7. () whether living in own or rented house
Whether Dry or wet land (i) if rented, mention rent amount
Annual Income from Agriculture 8. Telephone/mobile number
(c) Land
9. Total Family income from all sources
63034 142 s4
Lhereby declare that theaboOve informnation given is true & correct.Iwill be held liable lor any wrong inlormation given which 80,000
shall include cancellation of scholarshin recovery
ofamounts paid already ifany besides criminal action.

Nane &Signatureotudent: D.Sa1am D.Sai1am Name &Signature of Purcnt p- yadagri

EPASS Application ID :,,2 D2 3
Course: BE, hyes ADDRESS: HNO:--(76, Nara Dyadea
Mobile No
College:
College District:chaitanya
Mobile No:
Bharathi institute of Technolegy (CBIT)
fona xeddy 63034l43s4 phdrnceCndL)