GOVTERNMENT OF NCT OF DELHI DEPTT. FOR THE WELFARE OF SC/ST/OBC/MINORITIES

B-BLOCK, 2ND FLOOR, VIKAS BHAWAN, I.P. ESTATE, NEW DELHI-110002 Website. www.scstwelfare.delhigovt.nic.in.

APPLICATION FORM

FOR SCHOLARSHIP/ MERIT SCHOLARSHIP TO SC/ST/OBC/MIN.STUDENTS OF Class I To XII (2015-16)

Closing Date: -20/09/2015

1. One copy of the passport size photograph with signature of the students thereon. 2. One self attested copy of the mark sheet in respect of the last examination passed (OBC-VI to XII & SC/ST/MIN- IX to XII), no percentage of marks required for SC/ST/MIN Class I to VIII. 3 (i). Self Attested copy of Caste Certificate issued in the Name of Student/Father (in respect of SC/ST/OBC) &

affidavit (in Non-Judicial Stamp Paper of Rs. 10)- in respect of Minority Students by parent/guardian declaring his son/daughter belong to particular Minority Community.

(ii). Self Attested copy of Epic Card/Adhar Number, Ration Card, Land line telephone bill of MTNL Driving

License issued by GNCTD and Domicile issued by SDM in Delhi or Pass Book of National Banks (iii). Details of Student’s Bank account with MICR no. duly verified by concerned bank authority. 4. In case of minority students, declaration of minority status of the student by the parent in the form of an affidavit (in a non-judicial stamp paper of value Rs. 10/-). In case of minority students, five years residence proof in Delhi i.e. Ration Card/Epic is also required. 5. Self declaration of family income in the prescribed format is required (in case OBC/Minority students only).

Name of the School:………………………………………………………………….……...... Name of the student……………………………………………………………………. Date of Birth of Student……………………………………………………………………….. Name of Father/Guardian:……………………………………………………………………… Residential Address and Phone No:……………………………………………………........ ……………………………………………………………………………………………………….. Pin Code:- Mobile/Phone No.:- Class & Section in which he/she studying:…………………………………………………. Yearly Family Income (for OBC/Min. only):………………………………………………….

Percentage of last examination :……………………………………………………………… (Only for OBC-VI to XII & SC/ST/MIN- IX to XII)

Hosteller/Day Scholar……………………………………………………………………………

Whether belong to SC/ST/OBC/Min…………………………………………………………..

Certified that the information given above is true to the best of my knowledge & belief

Signature of the Parents/Guardian Signature of the student

Affix recent passport size photo of student duly signed by him/her

Performa Of Consolidated Statement by School (I-XII) (2015-16)

List of students eligible and recommended for Scholarship / Merit Scholarship

1. Name & address of the School (with ID) ______________________________________

S.No. Name & Roll No. Date of Birth Father’s /mother’s Class & Section Category

Of the student of the student Name in which SC/ST/OBC/Min Presently studying.

1 2 3 4 5 6 % of Marks obtained Amount of Family Income (for Remarks

in Previous Class Scholarship OBC/Min. Only) (if any) (only for OBC-VI to XII & SC/ST/MIN- IX to XII)

7 8 9 10 1. Certified that the above particulars have been checked with the office record and found correct. 2. Certified that no eligible students studying in the school is left out for grant of scholarship and this list may be treated as final. 3. Certified that these students have not been recommended for grant of scholarship in any other Scheme sponsored by Govt. of India. 4. Certified that the SC/ST/OBC certificates in respect of all the student/Father have been issued by the Tasildar/S.D.M, Dy. Commissioner (Revenue), Govt. of NCT of Delhi. Five years residence proof in Delhi i.e. Ration Card/EPIC(in case of Minority Student). 5. Certified that the scholarship for the year 2015-16 has already been disbursed to eligible students in presence of the authorized person and utilization certificate of the same is furnished in the Office of the Dy. Director (Planning), Patrachar Building, Timar Pur, Delhi. (in case of Govt./Aided Schools affiliated to Directorate of Education, Government of N.C.T. of Delhi). 6. Details of Student’s Bank account with MICR no. duly verified by concerned bank authority. 7. Certified that the all the requisite information/documents such as application forms, Caste certificate, marksheet Self declaration of family income, etc. are kept on school record. (in case of Govt./Govt. Aided/MCD/NDMC/DCB school only)

8. Certified that all the eligible students have been informed about the scheme and the salient features of the

scheme has been explained to the students in the morning assembly/parent-teacher meeting/ displayed prominently in the notice board of the School.

Signature with seal of Principal/Head of the School

* Applicant and form attesting authority/school authority, who gives false and fabricated

document/information will be prosecuted.

Self Declaration Format

The following information is to be provided by the claimant at the time of filing of forms: -

1. No. of family members:- Adult : - Minor : - Total : -

2. House owned if yes - Area of House & Property Tax: - If rented - Rent of the House (per month): -

3. Electricity bill amount (per month) : - 4. Gas/Kerosene Expenses (per month): -

5. No. of earning members & their total earning (per Month) : -

6. No. of studying members of family & their expense (per month): -

7. Vehicles used by the family

(Car/Scooter/Motor Cycle/ Bus) (per month) : -

8. Kitchen expenses (per month): -

9. Telephone use (Mobile or Landline) Monthly Bill (per month) : -

10. Total Annual Income : -

Name & Signature of the Parent

ELECTRONIC CLEARING SERVICE

(CREDIT CLEARING)

Student Bank Account Form (To be filled and attested by Bank/Branch)

1. Name of Account Holder:__________________________________________________

(Should be same as in School Records)

2. Account No.:

(Account for ECS Purpose)

3. Type of Account: Saving Current

4. Name of Bank:___________________________________________________________

5. Branch Name & Address:__________________________________________________

6. Branch Contact No.:______________________________________________________

7. MICR No.:

8. IFSC Code:

Remarks, if any __________________________________________________________________

Nationalized Bank only may be considered.

(Bank Seal) (Signature of Bank Authority)

Kindly Enclosed Photocopy of First page of Passbook with MICR number