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, 5. (i) No. of Vehicles owned by the Family
Designation
(iv) Salary per month (ii) Whether used for personal/private
use only
2. (i) Name of the Mother (iii) Mention type of vehicles (two Regd. No.
wheeler/ three wheeler/four wheeler)
(ii) Whether Employed (iv) Vehicle registered on whose name
(iii) if employed, 6. (i) Type of House: Mention whether
Designation RCC, thatched/Tiled roofed
(iv) Salary per month (ii) Mention whether Indiramma House
3. Agricultural holding of the (iii) Cost of Construction of House
parents mention extent
(i) In the name of the (iv) Whether Constructed with loan, if
Father so amount and Bank Branch
(ii) In the name of the (v) Any other type of house
Mother
(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 8 Telephone / Mobile Number
Agricultural Land
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 (2018-19):____________ Address: H.No.:____________
Course: ________ Course Year:_ Village & Mandal:___________
College: ____________________________________ ___________ City & District: _____________
College District:______________ Mobile No:_________
Mobile No:__________