(iii) Survey No. (v) Annual Income Rs. Rs. Rs.

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1 ANNEXURE III INCOME AFFIDAVIT Delaration of inome of Parent/Guardian for the year (ending on 31 st Marh,2008) for purposes of sholarships granted under the Central Setor Sheme of Sholarship for College and University Students. I, son/daughter of Shri/Smt presently residing at solemnly affirm and say as follows:- 1. That my son/daughter/dependent Shri/Kumari who has een provisionally seleted for Sholarship under the Central Setor Sheme of Sholarship For College and University Students, is studying in (here give the name of institution) 2. That my annual inome in the preeding year ending the 31 st Marh, 2008 is Rs. as per details furnished in the Sheduled here under written, I also affirm that partiulars of property held y me is as shown in the Shedule and that I have orretly indiated the amount on various taxes/esses and land revenue paid y me. I make myself personally responsile for the auray of the fats and figures furnished 3. That the statements made in the foregoing paragraphs are true to my knowledge. 4. That I further undertake that in the event of the partiulars given in this delaration eing found false, I shall refund to the President of India DOUBLE the amount of the sholarship to the said sholar(s) and the Government s deision on whether the delaration of partiulars is false shall e final and inding on me. Signature Name in full To e signed in the presene of Notary Puli or a Magistrate/Ist Class Magistrate Exeutive/ Revenue Offier/ who would also affix his signature and seal. SCHEDULE I Extent of Land held and Inome (a) Independently as owner (i) Area () Jointly as owner () Independently as tenant (ii) Village (iii) Survey No. (iv) Land Revenue Assessment (v) Annual Inome Rs. Rs. Rs. II Property held and inome (Houses, Shops, Buildings, House sites et.) (a) House No. () Street/Road () Village/Town/City (d) Area of Site (e) Rent derived if any (f) House Tax Rs. (a) Sanitary ess or other Rs. () Net Annual Inome Rs.

2 Whether the whole or part of land has een given out to tenants:. If yes partiulars. III Inome from Shops: (i) Address of shop (ii) Nature of trade (iii) Sales Tax, Inome Tax paid Rs. (iv) Liense No. (v) Annual Inome Rs. IV Salaries Drawn, y father and mother: (i) Name of the Employer (ii) Offie/Unit in whih working and designation (iii) Address of Offie (iv) (a) Annual Basi Pay for 2008 without dedution of Inome Tax (Certifiate from the employee/inome Tax Authority/Revenue Authority may e attahed) () Speial Pay/Bonus. () Deputation allowane and honoraria inluding NCC honoraria. (d) Total of (a), () and () (e) Amount of ontriution to Provident Fund (f) Payments towards LIC/CTD (g) Total of (e) and (f) (h) Whether elonging to non-reamy layer : YES / NO If Yes, attah ertifiate from employer. V Other enefits like house rent allowane, free house and other perquisites VI Other soure of Inome : (i) Inome from susidiary industries part-time oupation Rs. (ii) Amounts drawn as wages Rs. (iii) Any other Inome Rs. VII Annual inome of wife/husand and of the Sholar s Inome from any soure Rs. (a) Annual Basi Pay for 2008 without dedution of Inome Tax (Certifiate from the employee/inome Tax Authority/Revenue Authority may e attahed) () Speial Pay/Bonus. () Deputation allowane and honoraria inluding NCC honoraria. (d) Total of (a), () and () (e) Amount of ontriution to Provident Fund (f) Payments towards LIC/CTD (g) Total of (e) and (f) Signature of Parent/ Guardian of the Sholar N.B. 1. Total inome of the family should inlude inome only of father & mother of the Sholar and of no other memers though they may e earning, 2. If father is dead, mother s inome will e shown alongwith the inome, if any, in the Sholar own name from shares, property et. 3. If oth father and mother of the sholar are deeased the inome, if any, in the sholar s name only will e shown, and not the inome of the guardian who may e supporting the sholar. 4. Inome for the purpose of Means Test is defined as under:- a. In the ase of salaried lass, asi pay plus inome if any form other soures and would not inlude allowane like Dearness Allowane, City Compensatory Allowane et.. In the ase of inome from soure liale to inome tax, inome omputed (after dedution for reate ale items) for the purpose of assessment of inome tax, as per Inome Tax Rules for the year.. In the ase of inome not liale to inome tax, suh as inome from Agriulture, et. the net inome that is arrived at after dedution expenditure inurred for earning that inome.

3 GOVERNMENT OF INDIA MINISTRY OF HUMAN RESOURCE DEVELOPMENT DEPARTMENT OF HIGHER EDUCATION ANNEXURE IV CENTRAL SECTOR SCHEME OF SCHOLARSHIP FOR COLLEGE AND UNIVERSITY STUDENTS STATEMENT OF PARTICULARS Note: 1. Statement of Partiulars, Inome Affidavit and Joining report duly filled in should e handed over to the Head of the Institution, where the student has joined UG ourse. The Head of the Institution will forward it, to the In-Charge of Central Sholarship Sheme, Sholarship Division of the onerned Board from where the student has passed the Sr. Seondary Examination (Class XII) after attestation of Photo and Joining report. 2. Eah item should e read arefully efore the form is filled. No hange will e permitted after it has een sumitted. If any entry is found to e inorret the sholarship, if awarded, is liale to e anelled forthwith. 3. Inomplete statement or statement reeived after the presried date will not e onsidered. Reent Color Photograph of the Appliant attested and stamped y Prinipal of Institution where student is presently studying 4. Students may ensure that the ompleted Forms are forwarded y the Head of the Institution in time. 1. Name of the Candidate (In lok letters) (As per Class XII Certifiate) 2. Date of Birth (DD/MM/YY) (As per Class X Certifiate) 3. Sex : Male / Female 4. Category: SC/ST/OBC/ General (Pl. attah proof) 5. Details of Father / Guardian/husand as the ase may e a Name Permanent Home Address Profession / Designation with address Pin: 6. Details for Communiation a Address for Correspondene d Tel No. with STD Code Moile No. E Mail ID 7. Whether father/guardian is a itizen of India.? YES/NO 8. Total monthly inome of oth parents/guardian Rs. or husand s inome in ase of married unemployed girl student. An inome affidavit as per Annexure III should e attahed in support. Whether elonging to Non-reamy layer? YES / NO If Yes, attah ertifiate from Employer Pin:

4 Partiulars of Shool/Institution last attended Class XII a Name of Shool/Institution Date of entry (DD/MM/YY) Date of leaving (DD/MM/YY) d Remark, if any (IF THIS SPACE IS NOT SUFFICIENT SEPARATE SHEET MAY BE ATTACHED Details of Class XII Examination passed y the Candidate: a Name of the Examination passed Roll Numer Year of Passing 2008 d Name of the Board whih onduted the examination passed y the andidate together with its headquarters. e Total aggregate marks otained in the examination (in First five sujets) f Perentage of marks otained in aggregate Is the andidate in reeipt of any other sholarship from State Government or other institution or person? If Yes, partiulars should e given inluding the monthly rate and date from whih the sholarship is eing drawn. Partiulars of Savings Bank Aount of the Candidate a Aount Numer Yes / No Name and Address of the Bank Bank Code Numer 13. d RTGS:NEFT:IFSC Code (11 digit Code of the Bank) List of Enlosures sent with this statement (without enlosures appliation will not e onsidered): a d e Inome Affidavit (Annexure-III) Attested Copy of Marks Sheet of Senior Shool Certifiate Examination 2008 (Class XII Attested Copy of SC/ST/OBC Certifiate Joining Report (Annexure-V) If elonging to Non-reamy layer, Certifiate from Employer 14. Certified that the statement made y me in this form is orret. I delare that in ase I am seleted for a sholarship. I shall devote my full time to the ourse of study, and that I shall not reeive another stipend/sholarship from any other soure. Plae Date: Signature of andidate

5 ANNEXURE -V GOVERNMENT OF INDIA MINISTRY OF HUMAN RESOURCE DEVELOPMENT DEPARTMENT OF HIGHER EDUCATION CENTRAL SECTOR SCHEME OF SCHOLARSHIP FOR COLLEGE AND UNIVERSITY STUDENTS JOINING REPORT 1. This is to ertify that Shri/Smt./Kumari. S/o,W/o,D/o Shri/Smt. who has passed the.. (here give name of Examination passed) onduted y the..... (here give the Name of the Board from where passed Class XII) with Roll No.... and has een granted admission in this institution on the... day of for the ourse. He/She has started attending the First Year lass with effet from...., The ompleted Statement of Partiulars (Annexure IV) and the Inome Affidavit Form (Annexure III) are also enlosed Prinipal, Seal of the Institution Telephone No. With STD Code To In-harge of Central Sholarship Sheme Sholarship Division (Address of the Board from where the andidate has passed Class XII) In ase, you have passed lass XII in 2008 from CBSE, send the filled up attested Annexures to: The Deputy Seretary, Admn & Vigilane, Sholarship Division, Central Board of Seondary Eduation, 2, Community Centre, Preet Vihar, Delhi

CENTRAL SECTOR SCHEME OF SCHOLARSHIP FOR COLLEGE AND UNIVERSITY STUDENTS DATA SHEET. 3. Sex: Male Female

CENTRAL SECTOR SCHEME OF SCHOLARSHIP FOR COLLEGE AND UNIVERSITY STUDENTS DATA SHEET 1. Name of the Candidate (in Block letters, as per XII Certificate) 2. Date of Birth (DD/MM/YY) (as per X certificate)