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 (c) Independently as tenant
owner
(i) Area
(ii) Village
(iii) Survey No
(iv) Land Revenue
Assessment
(v) Annual Income Rs. Rs. Rs.
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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 _________________
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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.
