INCOME DECLARATION FORM Name of the Student: 1 (i) Name of the Father (ii) Whether Employed (iii) if employed,

Designation (iv) Salary per month 2 (i) Name of the Mother (ii) Whether employed (iii) if employed, Designation (iv) Approx salary per month

KONKA MARY ANTHAIAH NO

4 5

ANTHONAMMA

3 Agricultural holding of the parents mention extent (i) In the name of the Father 10 ACRE 7 (ii) In the name of the Mother (a) Crops Grown in land PADDY 8 (b) Whether Dry or Wet land WET 9 (c) Annual income from Agricultural 80000 Land Note: If any stage, it is found that the information given by me is false/not true, all benefits given t student under the "scholarship scheme for students belonging to the minority communities" could withdrawn and legal action as deemed fit, may be taken against me or my ward. Name & Signature of the Student Token Number of student: Date:Place:-

Business mention the trade/name of business Income derived from the venture (i)No. of Vehicles owned bythe 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: Mentionwhether RCC, thatched/Tiled roofed (ii) Mention whetherIndiramma House (iii) Cost of Constructionof House (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 Total Family income from all sources

NO Regd.No. ` RCC NO 80000 NO NO OWN 970350089 0 80000

mation given by me is false/not true, all benefits given to the tudents belonging to the minority communities" could be ay be taken against me or my ward. Name & Signature of the Parent Date:Place:-