Income Declaration Form for EPASS For all

Print the below income declaration on the

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

INCOME DECLARATION FORM

Name of the Student
1.	(i) Name of the Father			4.	Business mention the trade/name of business
	(ii) Whether Employed				Income derived from the venture
	(iii) if employed, Designation			5.	(i) No. of Vehicles owned by the Family
	(iv) Salary per month				(ii) Whether used for personal/private use only
2.	(i) Name of the Mother				(iii) Mention type of vehicles (two wheeler/ three wheeler/four wheeler)		Regd. No.
	(ii) Whether Employed				(iv) Vehicle registered on whose name
	(iii) if employed, Designation			6.	(i) Type of House: Mention whether RCC, thatched/Tiled roofed
	(iv) Salary per month				(ii) Mention whether Indiramma House
3.	Agricultural holding of the parents mention extent				(iii) Cost of Construction of House
	(i) In the name of the Father				(iv) Whether Constructed with loan, if so amount and Bank Branch
	(ii) In the name of the Mother				(v)  Any other type of house
(a)	Crops Grown in land			7.	(i) Whether living in own house or rented house
(b)	Whether Dry or Wet land				(ii) if rented, mention rent amount
(c)	Annual Income from Agricultural Land			8	Telephone / Mobile Number
				9.	Total Family income from all sources.

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                                                                            Name & Signature of the Parent

ePASS Application ID (2010-11):____________                                                  Address: H.No.:____________

Course: ­­­________    Course Year:_                                                                        Village & Mandal:___________            

College: ____________________________________          ___________          City & District: _____________

College District:______________                                                                          Mobile No:_________

Mobile No:__________