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FRESH

GOVERNMENT OF INDIA MINISTRY OF HUMAN RESOURCE DEVELOPMENT

DEPARTMENT OF HIGHER EDUCATION

CENTRAL SECTOR SCHEME OF SCHOLARSHIP FOR COLLEGE AND UNIVERSITY STUDENTS

STATEMENT OF PARTICULARS Note: 1. Statement of Particulars, Income Affidavit and Joining report duly filled in should be handed

over to the Head of the Institution, where the student has joined UG course. The Head of the Institution will forward it, to the Secretary, Senior Secondary Baord / Registrar of University after attestation of Photo and Joining report.

2. Each item should be read carefully before the form is filled. No change will be permitted after it has been submitted. If any entry is found to be incorrect the scholarship, if awarded, is liable to be cancelled forthwith.

3. Incomplete statement or statement received after the prescribed date will not be considered.

4. Students may ensure that the completed Forms are forwarded by the Head of the Institution in time.

1.

2.

3.

4.

Name of the Candidate (In block letters) (As per Class XII Certificate) Date of Birth (DD/MM/YY) (As per Class X Certificate) Sex : Male / Female

Category: SC/ST/OBC/ General : [Pl. attach proof] Physically Handicapped [Pl. attach proof)

Details of Father / Guardian/husband as the case may be a Name

b Permanent Home Address

Recent Color Photograph of the

Applicant attested and stamped by Principal of School/Institution where

student is presently studying

5.

Dist: Pin:

c Profession / Designation with address

6. Details for Communication a Address for Correspondence

Dist: Pin:

b Tel No. with STD Code

c

d

7. 8.

Mobile No.

E Mail ID

YES/NO Rs.

9.

Whether father/guardian is a citizen of India.: Total annual income of both parents/guardian or husband‟s income in case of married unemployed girl student. An income affidavit as per Annexure–III should be attached in support. Particulars of School/Institution last attended Class XII a Name of School/Institution

b c d

Date of entry (DD/MM/YY) Date of leaving (DD/MM/YY) Remark, if any (IF THIS SPACE IS NOT SUFFICIENT SEPARATE SHEET MAY BE ATTACHED

Details of Class XII Examination passed by the Candidate: a Name of the Examination passed b Roll Number c Year of Passing d Name of the Board which conducted the

examination passed by the candidate together with its headquarters.

e Total aggregate marks obtained in the examination (in First five subjects)

f Percentage of marks obtained in aggregate

Is the candidate in receipt of any other scholarship from State Government or other institution or person If Yes, particulars should be given including the monthly rate and date from which the scholarship is being drawn. Particulars of Savings Bank Account of the Candidate a Account Number

b Name and Address of the Bank

10.

11. Yes / No

12.

c

d

13.

Bank Code Number

RTGS:NEFT:IFSC Code (11 digit Code of the Bank)

List of Enclosures sent with this statement (without enclosures application will not be considered) a Income Affidavit (Annexure-III) b Attested Copy of Marks Sheet of Senior School Certificate Examination 2008 of CBSE c Attested Copy of SC/ST/OBC Certificate d Joining Report (Annexure-V)

15. Certified that the statement made by me in this form is correct. I declare that in case I am selected for a scholarship. I shall devote my full time to the course of study, and that I shall not receive another stipend/scholarship from any other source.

Signature of candidate

Place …………………

Date: ………………… ****

14. Aadhaar No:-

Annexure – I

MERIT LIST OF CANDIDATES OBTAINED 80% OR MORE MARKS

IN AGGREGATE IN THE SENIOR SECONDARY / +2 EXAMINATION

HELD IN 20…… FOR AWARD OF SCHOLARSHIP UNDER THE

SCHEME OF SCHOLARSHIP FOR COLLEGE AND UNIVERSITY

STUDENTS

Name of the University/Board………………………………………………. Aggregate Marks……………………… 1. Sl. No. 2. Name of candidate

in English & Hindi

(Devanagri Script) Percentage of marks Rank in the Examination State/Union Territory from which the candidate has passed Residential address of candidate Income of the parents / Guardians/Husband in the case of married unemployed girl student Sl. No. of the Entitlement Card issued

3. 4. 5. 6. 7.

8.

(To be signed alongwith seal by )

Secretary of the Board / Registrar of University

****

ANNEXURE – II

ENTITLEMENT CARD

GOVERNMENT OF INDIA MINISTRY OF HUMAN RESOURCE DEVELOPMENT

DEPARTMENT OF HIGHER EDUCATION SCHEME OF SCHOLARSHIP FOR COLLEGE AND UNIVERSITY STUDENTS

Name of Examination…………………………………………………………………… … Year and month in which Examination was held……………………………………… …. Serial No. in Merit List…………………………………………………………………….

1. The holder of this card, Shri/Smt./Kumari……………………………..……… … S/o. W/o. D/o. Shri……………………………………… has been provisionally selected for an award under the Scheme of Scholarship for College and University Students of the Government of India on the results of the Examination held by this Board/University in the month & year indicated above. He/She obtained …….. marks out of a total of …… and has secured the …………….. rank in the Merit List.

Signature

Seal of the

Secretary Board of Senior Secondary Education / Registrar of University

****

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)

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

That the statements made in the foregoing paragraphs are true to my knowledge.

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.

2.

3.

4.

Signature

Name in full

To be singed in the presence of Notary Public or a Magistrate/Ist Class Magistrate Executive/ Revenue Officer/ who would also affix his signature and seal.

SCHEDULE

Extent of Land held and Income

(i)

(ii)

Area

Village

(a) Independently as owner (b) Jointly as owner

(c) Independently as tenant

(iii) Survey No.

(iv) Land Revenue Assessment

(v) Annual Income Rs. Rs. Rs.

II Property held and income (Houses, Shops, Buildings, House sites etc.)

(a) (b) (c) (d) (e) (f)

(a)

(b)

House No. ________________________________________________ Street/Road ________________________________________________ Village/Town/City ________________________________________________ Area of Site ________________________________________________ Rent derived if any ________________________________________________ House Tax Rs.___________________________________________

Sanitary cess or other Rs.__________________________________________

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)

(iii)

(iv)

(v)

Nature of trade

Sales Tax, Income Tax paid

Licence No.

Annual Income

_________________________________________

Rs.______________________________________

_________________________________________

Rs.______________________________________

IV Salaries Drawn, by self / spouse :

(i)

(ii)

(iii)

(a)

Name of the Employer____________________________________________

Office/Unit in which working and designation____________________________________________

Address of Office____________________________________________

Annual Basic Pay for ---- (Year) without deduction of Income Tax (Certificate from the employer/Income Tax Authority/Revenue Authority may be attached)

Rs _________________________

(b)

(c)

Special Pay/Bonus.

Deputation allowance and honoraria including NCC honoraria

Rs _________________________

Rs_________________________

(d)

(e)

Total of (a), (b) and (c)

Amount of contribution to Provident Fund

Rs_________________________

Rs ________________________

Rs________________________ (f) Payments towards LIC/CTD

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.

Other benefits like house rent allowance, free house and other perquisites ____________ VI

VII Other source of Income :

(i) Income from subsidiary industries part-time occupation

(ii) Amounts drawn as wages

(iii) Any other Income

Rs. ________________________

Rs. ________________________

Rs. ________________________

VIII Annual income of wife/husband and of the Scholar‟s Income from any source

(a)

Rs. ________________________

Annual Basic Pay for ----(Year) without deduction of Income Tax Rs _________________________ (Certificate from the employer/Income Tax Authority/Revenue Authority may be attached)

Special Pay/Bonus. Rs _________________________ (b)

(c)

(d)

(e)

(f)

(g)

Deputation allowance and honoraria including NCC honoraria.

Total of (a), (b) and (c)

Amount of contribution to Provident Fund

Payments towards LIC/CTD

Total of (e) and (f)

Rs _________________________

Rs _________________________

Rs _________________________

Rs_________________________

Rs _________________________

Signature of Parent/ Guardian of the Scholar

N.B.

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 rebate able 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.

****

(1)

ANNEXURE -V

GOVERNMENT OF INDIA MINISTRY OF HUMAN RESOURCE DEVELOPMENT

DEPARTMENT OF HIGHER EDUCATION

CENTRAL SECTOR SCHEME OF SCHOLARSHIP FOR COLLEGE AND UNIVERSITY STUDENTS

JOINING REPORT

1. This is to certify that Shri/Smt./Kumari

Shri/Smt. ………………………………………………………………………. S/o,W/o,D/o

…………………………………………………………………………………………… who has passed the

Senior School Certificate Examination held in March/April 2013 conducted by the

Central Board of Secondary Education, Delhi with Roll No. …………….. and has been

granted admission in this institution on the …………….. day of …………………… for the

……………………………………………………………………… course. He/She has started attending

the First Year class with effect from ……………………………………., 2013.

2. The completed Statement of Particulars (Annexure–IV) and the Income Affidavit Form (Annexure–III) are also enclosed

Principal,

Seal of the Institution Telephone No. With STD Code

To

The Secretary Board of Senior Secondary Education / Registrar of University

****

RENEWAL APPLICATION FOR CENTRAL SECTOR SCHOLARSHIP 2013-14

1.Personal Information

Name of the Students:

Gender:

Category:

Contact Details:

Permanent Address:

City: Pin code:

District: Contact No:

Email Address:

2.Guardian Details

Name: Occupation: Designation:

Organization Name:

Organization Address

Annual Income:

3.Course Details:

Course Name: Course Year:

4.College Details

College Name:

College Address:

Pincode:

E-mail Address: Contact No:

5.Exam Details:

Is Promoted To Next Class?

Percentage Obtained in Annual/Semester Exam:

Dicipline Remarks of Students (Ragging Etc):

State and Board of Class XII Exam:

HSC Seat No: Year of Passing:

Renewal

6.Other Scholarship Details:

Is the Candidate In Receipt of Any Scholarship From State Govt OR other Institution?

YES / NO:

7.Bank Details:

Bank Name:

Branch Name:

Address:

Contact No:

IFSC Code: MICR Code:

Account No:

Aadhaar No:

Signature of the Principal/Head Of the Institute with College Seal

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)

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

That the statements made in the foregoing paragraphs are true to my knowledge.

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.

2.

3.

4.

Signature

Name in full

To be singed in the presence of Notary Public or a Magistrate/Ist Class Magistrate Executive/ Revenue Officer/ who would also affix his signature and seal.

SCHEDULE

Extent of Land held and Income

(i)

(ii)

Area

Village

(a) Independently as owner (b) Jointly as owner

(c) Independently as tenant

(iii) Survey No.

(iv) Land Revenue Assessment

(v) Annual Income Rs. Rs. Rs.

II Property held and income (Houses, Shops, Buildings, House sites etc.)

(a) (b) (c) (d) (e) (f)

(a)

(b)

House No. ________________________________________________ Street/Road ________________________________________________ Village/Town/City ________________________________________________ Area of Site ________________________________________________ Rent derived if any ________________________________________________ House Tax Rs.___________________________________________

Sanitary cess or other Rs.__________________________________________

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)

(iii)

(iv)

(v)

Nature of trade

Sales Tax, Income Tax paid

Licence No.

Annual Income

_________________________________________

Rs.______________________________________

_________________________________________

Rs.______________________________________

IV Salaries Drawn, by self / spouse :

(i)

(ii)

(iii)

(a)

Name of the Employer____________________________________________

Office/Unit in which working and designation____________________________________________

Address of Office____________________________________________

Annual Basic Pay for ---- (Year) without deduction of Income Tax (Certificate from the employer/Income Tax Authority/Revenue Authority may be attached)

Rs _________________________

(b)

(c)

Special Pay/Bonus.

Deputation allowance and honoraria including NCC honoraria

Rs _________________________

Rs_________________________

(d)

(e)

Total of (a), (b) and (c)

Amount of contribution to Provident Fund

Rs_________________________

Rs ________________________

Rs________________________ (f) Payments towards LIC/CTD

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.

Other benefits like house rent allowance, free house and other perquisites ____________ VI

VII Other source of Income :

(i) Income from subsidiary industries part-time occupation

(ii) Amounts drawn as wages

(iii) Any other Income

Rs. ________________________

Rs. ________________________

Rs. ________________________

VIII Annual income of wife/husband and of the Scholar‟s Income from any source

(a)

Rs. ________________________

Annual Basic Pay for ----(Year) without deduction of Income Tax Rs _________________________ (Certificate from the employer/Income Tax Authority/Revenue Authority may be attached)

Special Pay/Bonus. Rs _________________________ (b)

(c)

(d)

(e)

(f)

(g)

Deputation allowance and honoraria including NCC honoraria.

Total of (a), (b) and (c)

Amount of contribution to Provident Fund

Payments towards LIC/CTD

Total of (e) and (f)

Rs _________________________

Rs _________________________

Rs _________________________

Rs_________________________

Rs _________________________

Signature of Parent/ Guardian of the Scholar

N.B.

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 rebate able 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.

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(1)