ANNEXURE - III INCOME AFFIDAVIT Declaration of income of Parent/Guardian for the year (ending on 31st March, ) {Enter relevant year} for purposes of scholarships granted under the "Central Sector Scheme of Scholarship 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 been provisionally selected in _______________________________________________ under the "Central Sector Scheme of Scholarship For College and University Students", is studying in ____________________________________________________________________ (here give the name of institution) 2. That my annual income in the preceding year ending the 31st March, ______ is Rs. ________ as per details furnished in the Scheduled here under written. I also affirm that particulars of property held by me is as shown in the Schedule and that I have correctly indicated the amount on various taxes/cesses and land revenue paid by me. I make myself personally responsible for the accuracy of the facts 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 particulars given in this declaration being found false, I shall refund to the President of India DOUBLE the amount of the scholarship to the said scholar(s) and the Government's decision on whether the declaration of particulars is false shall be final and binding on me. Signature Name in full To be signed in the presence of Notary Public or a Magistrate/1st Class Magistrate Executive/Revenue Officer/Who would also affix his signature and seal. SCHEDULE I Extent of Land held and Income (a) Independently as owner (b) Jointly as owner (c) Independently as tenant (i) Area (ii) Village (iii) Survey No (iv) Land Revenue Assessment (v) Annual Income Rs. Rs. Rs. 2 II Property held and income (Houses, Shops, Buildings, House sites etc.) a) House No. __________________________________________________________ b) Street/Road __________________________________________________________ c) Village/Town/City __________________________________________________________ d) Area of Site __________________________________________________________ e) Rent derived if any __________________________________________________________ f) House Tax Rs._________________________________________________ (a) Sanitary cess or other Rs._________________________________________________ (b) Net Annual Income Rs._________________________________________________ Whether the whole or part of land has been given out to tenants. If 'yes' particulars. III Income from Shops : I. Address of shop ____________________________________________________ II. Nature of trade ____________________________________________________ III. Sales Tax, Income Tax paid Rs._________________________________________________ IV. Licence No. ____________________________________________________ V. Annual Income Rs._________________________________________________ IV Salaries Drawn, by self/spouse : I. Name of the Employer ____________________________________________________ II. Office/Unit in which working and designation ____________________________________________________ III. Address of Office ____________________________________________________ IV. a) Annual Basic Pay for ___ (Year) without deduction of Income Tax Rs.________________________ (Certificate from the employer/Income Tax Authority/Revenue Authority may be attached) b) Special Pay/Bonus Rs.________________________ c) Deputation allowance and honoraria including NCC Honoraria. Rs.________________________ d) Total of (a), (b) and (c) Rs.________________________ e) Amount of contribution to Provident Fund Rs.________________________ f) Payments towards LIC/CTD Rs.________________________ g) Total of (e) and (f) Rs.________________________ V. In case of Govt.Servants, Certificate may be given that you do not belong to 'creamy-layer', as per extant govt. instructions. VI. Other benefits like house rent allowance, free house and other perquisites _________________ 3 VII. Other source of Income : I. Income from subsidiary industries part-time occupation Rs.________________________ II. Amounts drawn as wages Rs.________________________ III. Any other income Rs.________________________ VIII. Annual income of wife/husband and of the Scholar's Income from any source Rs.________________________ a. Annual Basic Pay for ___ (Year) without deduction of Income Tax Rs.________________________ (Certificate from the employer/Income Tax Authority/Revenue Authority may be attached) b. Special Pay/Bonus Rs.________________________ c. Deputation allowance and honoraria including NCC Honoraria. Rs.________________________ d. Total of (a), (b) and (c) Rs.________________________ e. Amount of contribution to Provident Fund Rs.________________________ f. Payments towards LIC/CTD Rs.________________________ g. Total of (e) and (f) Rs.________________________ Signature of Parent/ Guardian of the Scholar N.B. 1) Total income of the family should include income only of father & mother of the Scholar and of no other members though they may be earning. 2) If father is dead, mother's income will be shown along with the income, if any, in the Scholar own name from shares, property etc. 3) If both father and mother of the scholar are deceased the income, if any, in the scholar's name only will be shown, and not the income of the guardian who may be supporting the scholar. 4) Income for the purpose of Means Test is defined as under :- a. In the case of salaried class, basic pay plus income if any form other sources and would not include allowance like Dearness Allowance, City Compensatory Allowance etc. b. In the case of income from source liable to income tax, income computed (after deduction for rebateable items) for the purpose of assessment of income tax, as per Income Tax Rules for the year. c. In the case of income not liable to income tax, such as income from Agriculture, etc. the net income that is arrived at after deduction expenditure incurred for earning that income.
