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.

Cost : ` 1/-

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 : ____________________________________________________

4 (i) Name of the Mother : ____________________________________________________

(ii) Whether Employed : ____________________________________________________

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

(iv) Salary per month : ____________________________________________________

5 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 (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 : ____________________________________________________

9 (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 OFFEREDSl. 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 & 35/-thereafter - 15 minutes

9 Residence Certificate 1st time - 7 days 2nd time & 35/-thereafter - 15 minutes

10 Integrated Certificate 1st time - 30 days 2nd time & 35/-(Caste-Nativity-Date of Birth) thereafter - 15 minutes

11 OBC Caste Certificate 1st time - 30 days 2nd time & 35/-thereafter - 15 minutes

12 EBC Certificate 1st time - 7 days 2nd time & 35/-thereafter - 15 minutes

13 Agricultural Income Certificate 1st time - 7 days 2nd time & 35/-thereafter - 15 minutes

14 No Earning Member Certificate 1st time - 7 days 2nd time & 35/-thereafter - 15 minutes

15 Family Member Certificate 1st time - 7 days 2nd time & 35/-(Social Security Schemes & thereafter - 15 minutesGovt. Employees / Pensioners)

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 charges5/- per additional copy

26 Death Certificate - GHMC 15 Mins. (Category-A) 25/- per transaction + statutory charges5/- 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 25/- per copy of certificate (within one year)

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 www.meeseva.gov.in