Income Fee Reimbursement Application Form

Cost : ` 1/-

AFFIDAVIT I, ______________________________________________________________________________________________, S/o, W/o, Sri _______________________________________________ aged about ____________ years having an occupation of __________________________________ resident of _______________________________ D. No ___________________ Locality\Landmark _________________________________ Village / town _________________________________________ Mandal _________________________________ District ________________________________________ Pincode do hereby solemnly affirm and state on oath as follows.

I am the deponent herein as such I am well acquainted with the facts of this affidavit. I submit that I am the resident of above address, I am doing __________________________________________ (Profession) and getting Rs. _____________________ in Rupees ___________________________________________________________________ only per annum from all sources mentioned below except the above said income. I belong to _________________ Caste, which comes under SC/ST/BC/Others. The income certificate is necessary for my Son / Daughter _________________________________________________ Who is studying _________________________________________ at _____________________ He / she required income certificate for getting scholarship / Fee reimbursement, hence I am giving this affidavit along with income declaration.

INCOME DECLARATION (As per G.O., RT No.1307, Rev., (Ser.II) Dept., and Dt.13.9.2010) 1

Name of the student

: ____________________________________________________

2

Date of Birth

: ____________________________________________________

3

(i) Name of the Father

: ____________________________________________________

(ii) Whether Employed

: ____________________________________________________

(iii) If employed designation, if not other profession

: ____________________________________________________

(iv) Salary per month

: ____________________________________________________

(i) Name of the Mother

: ____________________________________________________

(ii) Whether Employed

: ____________________________________________________

4

(iii) If employed, designation, if not other profession : ____________________________________________________

5

(iv) Salary per month

: ____________________________________________________

Agricultural holding of the parents mention extent

: ____________________________________________________

(i) In the name of Father

: ____________________________________________________

(ii) In the name of Mother

: ____________________________________________________

(a) Crops grown in land

: ____________________________________________________

(b) Whether Dry or wet land

: ____________________________________________________

I Annual income from agricultural land

: ____________________________________________________

6

Business mention the trade / name of business Income : ____________________________________________________ derived from the venture

7

(i) Number of vehicles owned by the family

: ____________________________________________________

(ii) Whether used for personal / private use only

: ____________________________________________________

(iii) Mention type of vehicles (two wheeler / three wheeler / four wheeler)

: Regd No. ____________________________________________

(iv) Vehicle registered on whose name

: ____________________________________________________

8

9

(i) Type of house mention Whether RCC / thatched / Tiled roofed (ii) Mentioned, whether Indiramma House

: ____________________________________________________

(iii) Cost construction of 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

: ____________________________________________________

10 Telephone/Mobile Number

: ____________________________________________________

11 Total family income from all sources

: ____________________________________________________

12 Ration Card Number

: ____________________________________________________

13 Aadhar Card Number

: ____________________________________________________

14 Email

: ____________________________________________________

I shall be liable for penal action both civil and criminal, if the above facts are false in future besides recovery of the scholarship with penal interest under the revenue recovery act. Therefore, I request the concerned revenue authorities may be pleased to accept this affidavit and issue income certificate to my son/daughter _______________________________________________ for scholarship / fee reimbursement purpose. The above facts are true and correct to the best of my knowledge and belief.

Name & signature of the student

Name & Signature of the Parent DEPONENT

Date: Place: Solemnly affirm and signed before me at on___________ Attested by: Signature of the Notary

SERVICES OFFERED Sl. No.

Service

Service Level

Service Charges (`)

1

Extract of Adangal / Pahani

15 Minutes *

25/-

2

Extract of ROR 1B

15 Minutes *

25/-

3

Copy of FMB

15 Minutes *

25/-

4

Copy of Village Map

5 Days

35/-

5

F-Line Petitions

30 Days

35/-

6

Sub-Division of Lands

30 Days

35/-

7

Mutation of Entries in Revenue Records

45 Days

35/-

8

Income Certificate

1st time - 7 days 2nd time & thereafter - 15 minutes

35/-

9

Residence Certificate

1st time - 7 days 2nd time & thereafter - 15 minutes

35/-

10

Integrated Certificate (Caste-Nativity-Date of Birth)

1st time - 30 days 2nd time & thereafter - 15 minutes

35/-

11

OBC Caste Certificate

1st time - 30 days 2nd time & thereafter - 15 minutes

35/-

12

EBC Certificate

1st time - 7 days 2nd time & thereafter - 15 minutes

35/-

13

Agricultural Income Certificate

1st time - 7 days 2nd time & thereafter - 15 minutes

35/-

14

No Earning Member Certificate

1st time - 7 days 2nd time & thereafter - 15 minutes

35/-

15

Family Member Certificate (Social Security Schemes & Govt. Employees / Pensioners)

1st time - 7 days 2nd time & thereafter - 15 minutes

35/-

16

Issue of Encumbrance Certificate

Same day, if submitted by 2 pm

25/-

17

Certified Copy of Registration Document

15 minutes

25/-

18

Money Lending License

Fresh - 45 days Renewal - 30 days

35/-

19

Allopathic Medical Care Registration

90 Days

35/-

20

Apathbandhu Scheme

10 Days

35/-

21

NFBS Application

1 Week

35/-

22

No Objection Certificate (Lands)

30 Days

35/-

23

Pawn Broker License

Fresh - 45 days Renewal - 30 days

35/-

24

School Registration

1 Week

35/-

25

Birth Certificate - GHMC

15 Mins. (Category-A)

25/- per transaction + statutory charges 5/- per additional copy

26

Death Certificate - GHMC

15 Mins. (Category-A)

25/- per transaction + statutory charges 5/- per additional copy

27

Birth Certificate Corrections - GHMC

6 Working Days

60/- + 25/- per copy of certificate

28

Death Certificate Corrections - GHMC

6 Working Days

60/- + 25/- per copy of certificate 10/- + 25/- per copy of certificate (after one year)

29

Child Name Inclusion - GHMC

6 Working Days (within one year)

25/- per copy of certificate

30

Non Availability Certificate Birth - GHMC

3 Working Days

25/- per copy of certificate

NOTE : 1. Postal charges extra. 2. *Subject to availability of online digital records, otherwise the request will be processed within 7 days. 3. Printing of additional pages at ` 2/- per page.

1100

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