INDIANINSTITUTEOFTECHNOLOGYDELHI

FAMILYINCOMESTATEMENT

1. NAMEOFTHESTUDENT________________________ENTRYNO.___________________________

2.PROGRAMME_______________________________________________________________________

3.HOSTELALLOTTED_____________________STUDENTSMOBILENO.______________________

PARENTSCONTACTNO._____________________
4.TOTALFEEOFSCHOOL/COLLEGE
GOINGBROTHERS/SISTERS______________________________________________________

5OCCUPATION/INCOMEOF_________________________________________________________
OTHEREARNINGFAMILYMEMBERS

FAMILYANNUALINCOME

SourceofIncome

Father

TotalAnnualIncome
Selfemployed*

Service*#/Pensioner*#
Other(Pl.specify)_________________
b

Mother

Selfemployed*

Service*#/Pensioner*#
Other(Pl.specify)________________
c

Anyother
FamilyIncome

Agriculture/FixedDeposit
/RentalIncome(Taxable)
Anyotherincome_____________
GrandTotal>

*I.T.R.Required(financialyear201314)
*#Form16andI.T.R.required(financialyear201314)

(SIGNATUREOFTHESTUDENT)(SIGNATUREOFTHEPARENT/GUARDIAN)

(OnlyforthoseinterestedinavailingMCM,Freeship,Freemessing&DonorScholarship
oranyotherbenefit)

The declaration of the Gross Annual family Income is a must for students seeking MeritcumMeans
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/Governmentorganization.TheformatforAffidavitisenclosed.

The Affidavit should be on a NonJudicial Stamp paper forRs.20/(or as perstate rules)sworn in before &signed by
a First Class Magistrate/ S.D.O./B.D.O/TEHSILDAR (on all pages) or any other revenue officer of the districtof
residence.AffidavitsignedbyNotary/OathCommissionerwillNOTbeaccepted.
Note:
1. MeritcumMeans (MCM) Scholarship MCM scholarship for the students (awarded up to 25% of the
total students admitted in the Institute on the basis of JEE merit) and subsequent renewal as per Institute
Rules.
2. Freeship Tuition Fee Waiver to the students (awarded up to 10% of the students admitted and
subsequentrenewalasperInstituteRules).
3. Free Messing SC/ST students are provided FreeMessing and subsequent renewal as per Institute
Rules.
4. Donor Scholarships Donor scholarships areavailable for students,on the basisof merit & annual family
incomeandsubsequentrenewalasperInstituteRules.

FORMATOFINCOMEAFFIDAVIT
TOBESUBMITTEDONNONJUDICIALSTAMPPAPEROFRS.20/(orasperStateRules)
ANDSWORNINBEFOREA
FIRSTCLASSMAGISTRATE/S.D.O./B.D.O./TEHSILDAR/
REVENUEOFFICEROFHISJURISDICTION

NameofStudent:.EntryNo..
ProgrammeNameHostel
(B.Techin..orDualDegree,B.Tech.in..&M.Tech.in..)

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

declare that my/our annual income from all sourcese.g.service/agricultural/trading/pension/interest/
(specify all types of other sources) including that of my spouse and
unmarried children is Rs(Rupees ...... only).
Thedetailsareasfollows:

1.Frommyprofession/Salary/pensionasindicatedRs._______________________p.a.
(Attachprooffromemployer/Form16/ITReturnetc.)

(A)

2.IncomefromBusiness/MedicalPracticeLegalPractice/EngineeringConsultancyetc.
Rs._______________________p.a.
3.IncomefromAgriculture

Rs._______________________p.a.

4.IncomefromlandProperties

Rs._______________________p.a.

5.IncomefromInvestmentinBank/PostOfficeetcRs._______________________p.a.
6.IncomefromShareCertificate/DebenturesRs._______________________p.a.
7.Incomefromanyothersources
(i.e.RetirementBenefitsforVRS/VSSetc.ifany)Rs._______________________p.a.

(B)

Incomeofmywife/husband(ifany)
Rs._______________________p.a.
(ifemployedsalarycertificateemployer/Form16tobeenclosed)

(C)

Incomeinthenameofmyson/ward(ifany

GROSSTOTALINCOME(A+B+C)

Rs._______________________p.a.
Rs._______________________p.a.

Further I declare that the information given above is true. I understand that the Meritcum Means
Scholarship/Freeship/Free Messing/Scholarship,ifawarded tomyson/daughter,isliabletobewithheld
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 beengranted any other Scholarship/ Stipend/ Fin. Assistance etc. by any Govt./ Nongovt.
organisation for the same period, I shall bound to refund the whole amount of Scholarship / Stipend/
Financial Assistance etc. to the scholarship awarding authority immediately.I shallalso be personally
held responsible forthe refund oftheScholarshipsamount(paidtomyson/daughterby theInstitute)in
theeventofanyinformationinthisdeclarationlateron.

_________________________
(SignatureofFather/Guardian)

Swornbeforemethis_________________dayof____________________2014andsigned.

(SEALwithdate)
_______________________________________
SignatureofFirstClassMagistrate/S.D.O./B.D.O./TEHSILDAR
oranyotherRevenueofficerofthedistrictofhis/herresidence

************

Note: The students are advised to keep a photocopy of the Income Affidavit
submittedatIITDelhiforfuturereference.