APPLICATION FOR AWARD OF "PERUNTHALAIVAR KAMARAJAR FINANCIAL ASSITANCE" TO Ist YEAR / IInd YEAR (LATERAL ENTRY) STUDENTS FORWARDING CERTIFICATE (This certificate should not be filled-in by the applicant. It should be filled-in by the Head of the Institution in which the applicant is a student in 200 - 200 ) 1. Name of the student (in BLOCK LETTERS) : 2. Name of the Examination Passed : 3. Name of Father / Guardian : 4. Class to which admitted {I Year / II Year (Lateral Entry)} : 5. CENTAC No. and Year (A copy of the CENTAC selection order to be closed) : 6. Year of Admission 7. The date on which the student joined the institution for the academic year 200 - 200 : Date Month Year 8. Year of passing : 9. Marks secured by the student and maximum marks : 10. Percentage of marks : 11. Community (Copy of the Community Certificate to be enclosed in the case of SC/ST/MBC/OBC) : SC / ST / MBC / OBC / Gen 12. The month and year in which the Annual University Examination will be ordinarily be over for the present class : 13. Students Bank A/c Details (a) Name of the Bank & Branch (b) Bank Account No. (Attested copy of the 1st Page of Bank Pass Book (or) Statement of A/c should be enclosed) : : Certified that the particulars furnished above have been verified by me and found correct. The application form has also been scrutinized and found to be in order and the candidate deserves to avail financial assistance. Place: Date : Signature of the Principal / Registrar (Office Seal) Education Department Puducherry 2 CHECK LIST FOR SCRUTINY OF APPLICATIONS FOR THE AWARD OF PERUNTHALAIVAR KAMARAJAR FINANCIAL ASSISTANCE TO THE STUDENTS STUDYING ________________________________________ COURSE 1. Name of the student (in BLOCK LETTERS) : 2. Class : 3. Name of the Institution where studying at present : 4. Qualifying Examination : 5. Total aggregate marks : 6. Percentage obtained in the above examination : 7. Whether the applicant is already in receipt of any other Scholarships, i.e. National Scholarship Scheme / Pondicherry State Post-Matric Scholarship / Scholarship from A.D. Welfare : 8. Whether the following enclosures attached to the applications i. Income Affidavit and Schedule of Property / Source of Income : ii. Attested copy of the mark sheets for the last Board / University Examination : iii. Community, Nationality and Residence Certificates : 9. Whether all the columns of the application duly filled in or not 10. Remarks Signature of the Head of the Institution 3 ANNEXURE - I (Rule IV) APPLICATION FORM FOR PERUNTHALAIVAR KAMARAJAR FINANCIAL ASSISTANCE TO THE STUDYING ___________________________________________________ COURSE I. Each item should be read carefully before the form is filled in. No change will be permitted after has been submitted. If any entry is found to be incorrect, the Financial Assistance, if awarded, will be liable to be cancelled forthwith II. Incomplete statement or statements received after the prescribed date will not be considered. 1. Name in full stating whether Shri/Smt./Kum. (in BLOCK LETTERS) : 2. (a) Exact date of Birth (In Christian era) : Date Month Year (b) Place, District and State of Birth (Nationality and Residence Certificate to be attached) : (c) Residential address of candidate : 3. Details of parents Father Mother (a) Name (b) Nationality (c) Whether alive (d) Occupation 4. Total monthly Income of Parent (See note 4 of Income Affidavit Pro forma). If, however, the applicant's father is dead the income of the widowed mother should be mentioned. If the applicant's father and mother are dead and he/she is looked after and supported by a guardian, then the income of the scholar alone from property, share or any other source should be mentioned. An Income Affidavit as in the form enclosed should be produced in support of this column. : Passport size photograph to be pasted here 4 5. Particulars of School / College / Institution last attended Name of School / College / Institution Date of Entry Date of Leaving Year Remarks, if any (1) (2) (3) (4) (5) 6. (a) Name of the last examination passed : (b) Year of passing : (c) Name of the authority (Board or University) which conducted the examination taken by the applicant together with the place of its headquarters : (d) Roll No. : (e) Total number of marks for the examination as a whole including the marks in the optional paper / papers, if these are counted by Board, University in awarding division (Attested copy of the marks sheet should be attached) : (f) Percentage of marks obtained in the aggregate : 7. If the candidate is in receipt of any Scholarship or Scholarships from a State Government or any other institution or persons, particulars should be given including the monthly rate and date from which the Scholarship is being drawn : 8. (a) Name and address of the institution where the Scholar has been admitted : (b) Course of Study : (c) Duration of the Course : 5 9. List of enclosures sent with the statement (please strike out that which is not applicable) (a) Income Affidavit and Schedule (Calculation of Income to be attached in the case of Salaried persons only) : (b) Attested copy of mark sheet for the last Board / University Examination (c) Community, Nationality and Residence Certificate Certified that the statements made by me in this form is correct. I declare that in case, I am selected for the Financial Assistance I shall devote my full time to the course of study, and that I shall not received another Scholarship from any other source. I shall seek permission from the Director of Higher & Technical Education in case I prefer to shift to another course in future. Place: Date : Signature of Student Countersigned Signature of the Principal / Registrar (Office Seal) 6 ANNEXURE - II INCOME AFFIDAVIT [Rule VII(3)] DECLARATION OF INCOME FOR THE YEAR 200 - 200 (ENDING 31ST MARCH OF A YEAR) FOR PURPOSE OF FINANCIAL ASSISTANCE UNDER THE SCHEME PERUNTHALAIVAR KAMARAJAR FINANCIAL ASSISTANCE TO THE STUDENTS STUDYING ________________________________________ COURSE I, .........................(Name of Father / Mother) Son / Daughter of Thiru.Tmt......................... at present residing at ........................................ solemnly affirm and says as follows:- 1. That my Son/Daughter Thiru/Selvi............... (Name of the student) who is applying for the grant of Financial Assistance under the Scheme Perunthalaivar Finance Assistance to the students studying ............. course is studying in ............................... (Name of the institution) 2. That my annual income in the preceding year ending 31st March 200. is Rs......... (Rupees .......................... only) as per details furnished in the Schedule hereunder written. I also affirm that particulars of property held by me are 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 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 to be false, I shall refund to the Government of Puducherry double the amount of the Financial Assistance paid to the said Awardee and the Government's decision on whether the Declaration of particulars is false shall be final and binding on me. SCHEDULE Signature Signature of Executive Magistrate Name in full : (To be signed in the presence of Executive Magistrate who affixes his seal and signature) 7 SCHEDULE (All the columns in the Schedule should be filled in properly by Words and not by Dashes or Dots) I. Extent of land held and income - (a) Independently as owner - i) Area ii) Village iii) Survey No. iv) Land Revenue Assessment v) Annual Income : : : : : Rs. (b) Jointly as owner - i) Area ii) Village iii) Survey No. iv) Land Revenue Assessment v) Annual Income : : : : :Rs. (c) Independently as tenant - i) Area ii) Village iii) Survey No. iv) Land Revenue Assessment v) Annual Income : : : : :Rs. (d) Jointly as tenant - i) Area ii) Village iii) Survey No. iv) Land Revenue Assessment v) Annual Income of the Scholar's Father / Mother : : : : :Rs. 8 II. Property held and Income (Houses, shop, buildings, house-sites, etc.) i) House No. ii) Street / Road iii) Village / Town / City iv) Area of Site v) Rent derived, if any vi) House Tax Paid vii) Sanitary cess or other house taxes paid viii) Net Annual Income after deduction of items (vi) and (vii) : : : : : : : : III. Income from shops i) Address of Shop ii) Nature of trade iii) Sales / Tax Income Tax Paid iv) Licence No. v) Rent derived, if any vi) Annual Income : : : : : : Rs. IV. Salaries drawn i) Name of the employer ii) Office / Unit in which he is working and designation iii) Address of Office iv) Annual emoluments for 200___ - 200___ : : : : : Break up for annual emoluments - Basic Pay D.A. / A.D.A. H.R.A. etc. O.T.A. / Bonus Others : Rs. : Rs. : Rs. : Rs. : Rs. Total : Rs. (Annexure has to be attached from the Pay Drawing Officer in respect of salaried person) 9 V. Other Source of Income i) Income from subsidiary industries / Part time occupation ii) Amount drawn as wages iii) Any other income : Rs. : Rs. : Rs. VI. Annual Income of wife and the scholar from any source : VII. Total income of the family for the whole year 200___ - 200____ : Rs. Average Income of the family for one month : Rs. Signature of the Parent of Scholar Note: (1) Total Income of the family should include income of father, mother and the scholars and of no other members though they may be earning. (2) If father is dead then mother's income will be shown alongwith the income, if any in the scholar's own name from shares, property, etc. (3) If both father and mother of the scholar are deceased, then the income, if any, in the scholar's name only will be shown and not he income of any guardian who may be supporting the scholar. (4) A detailed break-up from the annual emolument shown under Column No.IV (Salaries drawn) as required against the column should invariably be furnished. 10 SELF AFFIDAVIT (To be furnished in Stamped Paper worth Rs.5/-) I, ................. Son/Daughter of ............... . Puducherry, under the Sponsored Quota of Government of Puducherry, hereby declare that the information regarding Income, Residence/Nativity furnished by me along with the applications for the Award of Perunthalaivar Kamarajar Financial Assistance are true and correct. Further I declare that I shall devote my full time to the course of study for which I have applied / received the Scholarship. Further I undertake in the event of particulars given in this Declaration being found to be false or become ineligible for receipt of the Financial Assistance I shall refund the double the amount of the Financial Assistance received by me to the Government of Puducherry. Signature of the Student Date: Name Address Withess 1. Name Address Withess 2. Name Address 11 CHECK LIST (FRESH) 1. Name of the student : 2. Name of the Institution : 3. Course of Present Study : 4. Category : SC / ST / OBC / MBC / General (FOR DIRECTORATE OF HIGHER & TECHNICAL EDUCATION OFFICE USE ONLY) 5. Copy of CENTAC Selection Order : Enclosed / Not Enclosed 6. Self Affidavit : Enclosed / Not Enclosed 7. Income Affidavit : Enclosed / Not Enclosed 8. Income Limit : Below Rs.3 Lakhs / Rs.3 to 5 Lakhs 9. Caste Certificate (In case of SC / ST / OBC / MBC) : Enclosed / Not Enclosed 10. +2 Mark List : Enclosed / Not Enclosed 11. Application duly filled in : Yes / No 12. Nationality & Residence Certificate : Enclosed / Not Enclosed 13. Attested copy of 1st Page of Bank Pass Book / Account Statement : Enclosed / Not Enclosed SIGNATURE OF DEALING ASSISTANT SECTION HEAD
