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Annexure : II

FORM – A

 

ANNUAL INCOME CERTIFICATE FOR THOSE PARENTS/GUARDIANS WHO ARE IN SERVICE

(Govt or Pvt.)

PART – I :                                                   Income from Salary :

 

  1. Name and Address of the Employer :
  1. Certified that ____________________________________________ is employed in this    Organisation____________________________________________________________(Name of the organisation), in the Post of _______________________________,(Designation held by the employee) and that the break-up of his Gross Annual Income from Salary received in the Financial Year ____________ is as follows :

 

                    ITEM

TOTAL AMOUNT FOR 12 MONTHS

 

 

 i)

Basic Pay                      

 

 

 

ii)

D/Pay                                   

 

 

 

iii)                    

DA/ADA/Relief

 

 

 

iv)

H. R.A.

 

 

 

iv)          

Special Pay & Honorarium, Bonus, Arrears, etc. ,if any

 

 

 

v)

Other Allowances, if any

 

 

 

Gross Income

 

 

Net Income

 

 

 

 

Name :

Signature:
Designation:
Contact No& Mail ID:         

 

 
         Date :

         (Official Seal)

 

N.B. 1): All the entries as stated above must be supported by Latest Copy of ITR Processed form for the latest Assessment Year if applicable.

2) Guardians whose annual gross income is low and need not submit Latest Copy of ITR Processed form, have to submit (i) A certificate from Employer/Salary disbursing officer stating that their annual income is Not Taxable and they need not produce Latest Copy of ITR Processed form and (ii) Attested copies of latest Annual Income Certificate from District Authority like S.D.O./B.D.O./TAHSILDAR, Anchal Officer, Executive Officer of Municipal Corporation/ Gram Panchayat etc.

PART – II   :                                   Income from other Sources           

DECLARATION BY THE FATHER /GUARDIAN OF THE STUDENT

 

I declare that my/my family’s Annual Income from other sources during the Financial Year­­­­­

____________________ was as follows in addition to my Salary Income:

 

Income from:

Amount in Rs.

a)

Landed Properties (Certificate from Tahsildar/Gram Panchayat)

 

b)

Agriculture

 

c)

Investment in Bank/Post Office/Unit Trust etc.

 

d)

Share Certificates/Debentures

 

e)

Other Sources

 

f)

Total of Salary Income as stated in item No.2  of Part-I , ( Pl. see pre-page)

 

      Gross Total Annual Income (add all of the above)

Rs.

 

Further, I declare that the information given above is true. I shall also be personally held responsible in the event of any information or documents provided by me are found to be incorrect/false.

 

          


Date :

Signature of the Father /Guardian

:

 

Full Name

:

 

Address with Pin Code

:

 

              

              Phone No. & e-mail ID

:

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