INCOME DECLARATION FORM

Name of the Student

: S.KALYAN KUMAR YADAV

(i) Name of the Father

1.

3.

4.

(ii) Whether Employed

(iii) if employed, Designation

(iv) Salary per month

(ii) Whether Employed

(iii) if employed, Designation

(iv) Salary per month

Agricultural holding of the
parents mention extent

(iii) Cost of Construction of House

(i) In the name of the Father

(ii) In the name of the Mother

No

Crops Grown in land

(b)

Whether Dry or Wet land

Annual Income from
Agricultural Land

Daily wages
worker

Income derived from the venture

5.

Late S. JANAKI

(a)

(c)

Business mention the trade/name of

business
(i) No. of Vehicles owned by the Family
(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

(i) Name of the Mother

2.

S.BHASKAR

6.

7.

(iv) Whether Constructed with loan, if so

amount and Bank Branch
(v) Any other type of house
(i) Whether living in own house or rented
house
(ii) if rented, mention rent amount
Telephone / Mobile Number

RCC
_
Own House
9059781664

9.
Total Family income from all sources.
Rs. 60,000/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: Sr. Intermediate (M.P.C)
College: Rayalaseema Junior College, Srikalahasti
College District: Chittoor District

Name & Signature of the parent

H.No.: 1/1364 N.T.R Nagar Srikalahasti
Address: Srikalahasti Mandal, Chittoor District
Mobile No: 9059781664