PRIMATRIC 2016-17
SELF DECLARATION OF FAMILY INCOME, COMMUNITY
AND INSTITUTION VERIFICATION FORM
UNDER PRE,POST MATRIC SCHOLARSHIP (CLASS XI AND ABOVE)/MERIT-CUM-MEANS
SCHOLARSHIP SCHEME OF MINISTRY OF MINORITY AFFAIRS, GOVERNMENT OF INDIA
I, ___________________________Son/Daughter/of____________________________________
Resident of (full address) _________________________________________________________
______________________________________________________________do hereby solemnly
affirm and declare as under :-
a) That I am citizen of India. Belongs to ______________________________ State &
_________________________Community
b) That annual income of my family from all sources is Rs …………………(in words also)
...………………………………………………………………………………………..
c) I declare that my father/mother/both* is/are earning Member(s) in my family.
2. I certify that the above information given by me is true.
3. I am not availing any other Scholarship for this purpose from any other Central Govt./ State
Govt. source.
4. I Shall abide by the terms and conditions for sanction of the Pre /Post Matric / Merit cum
Means based Scholarship.
5. In case this information furnished by me is found false, the financial assistance awarded to me
may be recovered with penal interest and I will be liable to a legal action against me in
accordance with law.
Signature of Candidate:_______________________ Signature of Parent/Guardian ___________
Name of Candidate: __________________________ Name of Parent/Guardian ______________
Verification/Information to be furnished by the Head of Institution/College
It is certified that the information provided below in respect of (He/She)
______________________ who is admitted in ___________________ course for the academic
session ________________ in __________________________________ is correct. He/ She is a
hosteller/day scholar of the Institution/College.
Last year marks percentage (%):___________. Fee details current Year: ___________________.
He / She belongs to ____________________ community as per Institution / College records.
For Renewal of Scholarship : It is certified that the student has not changed the course of study
and/or the Institution of the study for which the scholarship was originally awarded / has changed
the course of study and/or institution with prior approval of the State Government (Please strike
out which is not applicable.
I certify that the above information furnished by the Institution / College is correct to the best of
my knowledge and as per information available on our records.
Date : Signature of the head of the Institution/College ____________________
Place: with official seal.
SELF DECLARATION OF FAMILY INCOME, COMMUNITY
AND INSTITUTION VERIFICATION FORM
UNDER PRE,POST MATRIC SCHOLARSHIP (CLASS XI AND ABOVE)/MERIT-CUM-MEANS
SCHOLARSHIP SCHEME OF MINISTRY OF MINORITY AFFAIRS, GOVERNMENT OF INDIA
I, ___________________________Son/Daughter/of____________________________________
Resident of (full address) _________________________________________________________
______________________________________________________________do hereby solemnly
affirm and declare as under :-
a) That I am citizen of India. Belongs to ______________________________ State &
_________________________Community
b) That annual income of my family from all sources is Rs …………………(in words also)
...………………………………………………………………………………………..
c) I declare that my father/mother/both* is/are earning Member(s) in my family.
2. I certify that the above information given by me is true.
3. I am not availing any other Scholarship for this purpose from any other Central Govt./ State
Govt. source.
4. I Shall abide by the terms and conditions for sanction of the Pre /Post Matric / Merit cum
Means based Scholarship.
5. In case this information furnished by me is found false, the financial assistance awarded to me
may be recovered with penal interest and I will be liable to a legal action against me in
accordance with law.
Signature of Candidate:_______________________ Signature of Parent/Guardian ___________
Name of Candidate: __________________________ Name of Parent/Guardian ______________
Verification/Information to be furnished by the Head of Institution/College
It is certified that the information provided below in respect of (He/She)
______________________ who is admitted in ___________________ course for the academic
session ________________ in __________________________________ is correct. He/ She is a
hosteller/day scholar of the Institution/College.
Last year marks percentage (%):___________. Fee details current Year: ___________________.
He / She belongs to ____________________ community as per Institution / College records.
For Renewal of Scholarship : It is certified that the student has not changed the course of study
and/or the Institution of the study for which the scholarship was originally awarded / has changed
the course of study and/or institution with prior approval of the State Government (Please strike
out which is not applicable.
I certify that the above information furnished by the Institution / College is correct to the best of
my knowledge and as per information available on our records.
Date : Signature of the head of the Institution/College ____________________
Place: with official seal.
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