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06_07_FORMS D_E

The document outlines the Family Income Statement and Income Declaration required by students at the Indian Institute of Technology Delhi seeking financial assistance such as Merit-cum-Means scholarships, freeships, and donor scholarships. It includes sections for reporting family income sources and mandates an affidavit on non-judicial stamp paper to be sworn before a revenue officer. The document also specifies income thresholds for eligibility and the consequences of providing false information.

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Sushovan Choudhuri
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25 views

06_07_FORMS D_E

The document outlines the Family Income Statement and Income Declaration required by students at the Indian Institute of Technology Delhi seeking financial assistance such as Merit-cum-Means scholarships, freeships, and donor scholarships. It includes sections for reporting family income sources and mandates an affidavit on non-judicial stamp paper to be sworn before a revenue officer. The document also specifies income thresholds for eligibility and the consequences of providing false information.

Uploaded by

Sushovan Choudhuri
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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Form “D”

Form D”

INDIAN INSTITUTE OF TECHNOLOGY DELHI

FAMILY INCOME STATEMENT

NAME OF THE STUDENT________________________ ENTRY NO. ___________________________

PROGRAMME _________________________________ALL INDIA RANK_______________________

CATEGORY _________________________________CATEGORY RANK ______________________

HOSTEL ALLOTTED ____________________________STUDENT’S MOBILE NO.________________

FAMILY ANNUAL INCOME


Source of Income Total Annual Income
a Father
Self employed /
Service
Other (Pl. specify)_________________
b Mother
Self employed /
Service
Other (Pl. specify) ________________
c Any other
Family Income
Grand Total

(SIGNATURE OF THE STUDENT) (SIGNATURE OF THE PARENT/GUARDIAN)


INCOME DECLARATION

(Only for those interested in availing MCM, Freeship, Free messing & Donor Scholarship)

The declaration of the Gross Annual family Income is a must for students seeking Merit-cum-Means
scholarship/Freeship/Free messing and any other Donor scholarship. For this purpose, an Affidavit alongwith
income certificate(s) is to be submitted by the Parent(s) whether in business/employment or in service with
Private/Government organization. The format for Affidavit is provided in Form E

The Affidavit should be on a Non-Judicial Stamp paper for Rs.20/- sworn in before a First Class Magistrate/
S.D.O./B.D.O/TEHSILDAR or any other revenue officer of the district of residence. Affidavit signed by
Notary/Oath Commissioner will NOT be accepted.

Note:
1. Merit-cum-Means (MCM) Scholarship – MCM scholarship for the students whose annual family
income is upto 4.5 lac (awarded up to 25% of the total students admitted in the Institute on the basis
of JEE merit).
2. Freeship – Tuition Fee Waiver to the students whose annual family income is upto 4.5 lac (awarded
up to 10% of the students admitted).
3. Free Messing - SC/ST students with Parental Income upto 4.5 lac are provided Free-Messing.
4. Donor Scholarships - Donor scholarships are available for students, on the basis of merit & annual
family income not exceeding 5.00 lac.
***********
Form E

FORMAT OF INCOME AFFIDAVIT


TO BE SUBMITTED ON NON-JUDICIAL STAMP PAPER OF RS.20/-
AND SWORN IN BEFORE A
FIRST CLASS MAGISTRATE/ S.D.O./ B.D.O./ TEHSILDAR /
REVENUE OFFICER OF HIS JURISDICTION

Name of Student: …………………………………………………….Entry No ……………………………..


Programme Name ……………………………………………………………………………………
(B.Tech in ….. or Dual Degree, B.Tech. in ….. & M.Tech. in ….. …)

I,……………………………………….., father/mother/guardian of Mr./Ms.......…..……………………….


declare that my/our annual income from all sources e.g. service/ agricultural/ trading/ pension/
interest/ …………………………… (specify all types of other sources) including that of my spouse
and unmarried children is Rs……………………(Rupees ……..………………….……………..….……
only). The details are as follows:

(A) 1. From my profession/ Salary/ pension as indicated Rs._______________________p.a.


(Attach proof from employer/ Form 16/ IT Return etc.)
2. Income from Business/ Medical Practice Legal Practice/ Engineering Consultancy etc.
Rs._______________________p.a.

3. Income from Agriculture Rs._______________________p.a.


4. Income from land Properties Rs._______________________p.a.
5. Income from Investment in Bank/ Post Office etc Rs._______________________p.a.
6. Income from Share Certificate/ Debentures Rs._______________________p.a.
7. Income from any other sources
(i.e. Retirement Benefits for VRS/ VSS etc. if any) Rs._______________________p.a.

(B) Income of my wife/ husband (if any) Rs._______________________p.a.


(if employed salary certificate employer / Form 16 to be enclosed)

(C) Income in the name of my son/ daughter Rs._______________________p.a.

GROSS TOTAL INCOME (A+B+C) Rs._______________________p.a.

Further I declare that the information given above is true. I understand that the Merit-cum Means
Scholarship/Freeship/Free Messing/Scholarship, if awarded to my son/ daughter, is liable to be
withheld or discontinued at the discretion of the authorities of the Indian Institute of Technology
Delhi without assigning any reason. If subsequently (after award of the Scholarship to my ward) it is
found that he/she has been granted any other Scholarship/ Stipend/ Fin. Assistance etc. by any
Govt./ Non-govt. organisation for the same period, I shall be bound to refund the whole amount of
Scholarship / Stipend/ Financial Assistance etc. to the scholarship awarding authority immediately. I
shall also be personally held responsible for the refund of the Scholarships amount (paid to my son/
daughter by the Institute) in the event of any information in this declaration being found incorrect/
false later on.

_________________________
(Signature of Father/Guardian)

Sworn before me this _________________ day of ____________________ 2013 and signed.

(SEAL with date)


_______________________________________
Signature of First Class Magistrate/ S.D.O./B.D.O./ TEHSILDAR
or any other Revenue officer of the district of the signatory.
************
Note: The students are advised to keep a photocopy of the Income Affidavit
submitted at IIT Delhi for future reference.

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