Form B

(PG)

INDIAN INSTITUTE OF TECHNOLOGY DELHI

Undertaking by the Student of awareness of academic rules at IIT Delhi

I,<Name>

son/daughter/ward of Mr./Ms..Entry No will go

through the Prospectus and Courses of Study for the academic year 2017-2018

available on the IITD website at http://www.iitd.ac.in/content/curriculum-info . I hereby

give an undertaking that I shall abide by the rules and regulations of the Institute in

general and specifically regulations stated in the Courses of Study 2017-2018 and any

modifications/ additions to those, which may be duly notified by competent authority.

Date Signature of the Student

*************
 FORM C
(PG)
INDIAN INSTITUTE OF TECHNOLOGY DELHI

BENEVOLENT FUND SCHEME

FORM FOR NOMINATION BY STUDENTS

I hereby nominate the person mentioned below, who is a member of my family, to receive amount of
out-right grant as per prescribed rate laid down in the Benevolent Fund Scheme Rules (BFSR) in the
event of my death due to an accident while undergoing studies at the Institute.

Relationship with Age

Name and Address of the Nominee member-student of BFSR

Dated this _________________ day of ____________________ at IIT Delhi, New Delhi-110 016.

_________________________________________
Signature of Member-student of Benevolent Fund

Entry No.: __________________ Student Name: _____________________________________

Witnesses to the signature of the Member-student:

1. Signature ____________________________________________________________

Name ____________________________________________________________

Address ____________________________________________________________

____________________________________________________________

____________________________________________________________

2. Signature ____________________________________________________________

Name ____________________________________________________________

Address ____________________________________________________________

____________________________________________________________

____________________________________________________________
-------------------------------------------------------------------------------------------------------------------------
For official use
Accepted _______________________________

Signatures ______________________________

Designation _____________________________
 Form D
(PG)

INDIAN INSTITUTE OF TECHNOLOGY DELHI

INSURANCE SCHEME OF IIT DELHI

FORM FOR NOMINATION BY STUDENT
(ONLY FOR FULL-TIME STUDENTS)

Name of Student ____________________________________________________________

Entry No. ________________________________

Programme _______________________________________________________________

Mothers Name ____________________________________________________________

Fathers Name ______________________________________________________________

Permanent Address __________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

I, having been covered, under the Insurance Scheme of I.I.T. Delhi, hereby nominate the persons
mentioned below, who are members of my family to receive the amount of insurance in the event of my
death.

Name and address of Relationship with student Age

1st Nominee____________________________________ ____________________ ______

______________________________________________

2nd Nominee ___________________________________ ____________________ ______

______________________________________________

__________________ Signature of student __________________________________

(Date)
Present Address _____________________________________
(of student)
_______________________________________

_______________________________________
Witness signatures (other than nominee)
1. Signature _________________________ 2. Signature _______________________
Name ____________________________ Name ____________________________
(in capitals) (in capitals)
Address __________________________ Address __________________________
__________________________________ _________________________________
__________________________________ _________________________________
 Form E

INDIAN INSTITUTE OF TECHNOLOGY DELHI

THE HONOUR CODE

I_______________________________________, Entry No._____________________, do hereby

undertake that as a student at IIT DELHI:

(1) I will not give or receive aid in examinations; that I will not give or receive unpermitted aid in
class work, in preparation of reports, or in any other work that is to be used by the instructor
as the basis of grading; and

(2) I will do my share and take an active part in seeing to it that others as well as myself uphold
the spirit and letter of the Honour Code.

I realize that some examples of misconduct which are regarded as being in violation of the Honour
Code include:

copying from another's examination paper or allowing another to copy from one's own paper;
unpermitted collaboration;
plagiarism;
revising and resubmitting a marked quiz or examination paper for re-grading without the
instructor's knowledge and consent;
giving or receiving unpermitted aid on take-home examinations;
representing as one's own work the work of another, including information available on the
Internet; and
giving or receiving aid on an academic assignment under circumstances in which a reasonable
person should have known that such aid was not permitted.
committing a cyber offence, such as, breaking passwords and accounts, sharing passwords,
electronic copying, planting viruses, etc.

I accept that any act of mine that can be considered to be an Honour Code violation will invite
disciplinary action.

Date: _______________ Student's signature ________________________________

Name __________________________________________

Entry No. ___________________________

NOTE TO THE STUDENT

Submit one signed copy at Registration.
Keep one signed copy with you.
Keep one signed copy with your parent(s)/guardian.

***********
 Form DF
Form
(PG)
INDIAN INSTITUTE OF TECHNOLOGY DELHI

FAMILY INCOME STATEMENT

(ONLY FOR MSc STUDENTS)

NAME OF THE STUDENT________________________ ENTRY NO. ___________________________

PROGRAMME _________________________________ALL INDIA RANK_______________________

CATEGORY _________________________________CATEGORY RANK ______________________

HOSTEL ALLOTTED ____________________________STUDENTS MOBILE NO.________________

AADHAR No.___________________________________ PAN No.______________________________

FAMILY ANNUAL INCOME

Source of Income Total Annual
Income
a Father Aadhar No PAN No.
Self employed /
Service
Other (Pl. specify)____________
b Mother
Self employed /
Service
Other (Pl. specify) ___________
c Any other
Family Income
Grand Total

Supporting Documents to be submitted:

Salaried Income Tax Return (ITR)/ Form-16 and Copy of Aadhar and PAN
Self Employed Income Tax Return (ITR)/ Income Certificate and Copy of Aadhar and PAN
BPL card holders Attested copy of the BPL card and Copy of Aadhar and PAN

Income Certificate should be duly signed by a First Class Magistrate/ S.D.O./B.D.O/TEHSILDAR of the district of
residence. Income Certificate signed by Notary/Oath Commissioner will NOT be accepted.

(SIGNATURE OF THE STUDENT) (SIGNATURE OF THE PARENT/GUARDIAN)

***********
 INCOME DECLARATION

The declaration of the Gross Annual family Income is a must for students seeking Institute scholarships and any other
Donor scholarship. For this purpose, income certificate is to be submitted by the Parent(s) whether in
business/employment or in service with Private/Government organization.

The income certificate should be duly signed ON ALL PAGES by a First Class Magistrate/ S.D.O./B.D.O/TEHSILDAR
of the district of residence. Income Certificate signed by Notary/Oath Commissioner will NOT be accepted.
-------------------------------------------------------------------------------------------------------------------------------------
ONLY FOR MSc STUDENTS Form G
(FORMAT OF INCOME CERTIFICATE) (PG)
Name of Student: .Entry No ..
Programme Name Cat(Gen/OBC/SC/ST/PD..
(B.Tech in .. or Dual Degree in .. )

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

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

(A) 1. From my profession/ Salary/ pension as indicated Rs._______________________p.a.

(Attach proof from employer/ Form 16/ IT Return etc.)
2. Income from Business/ Medical Practice Legal Practice/ Engineering Consultancy etc.
Rs._______________________p.a.

3. Income from Agriculture Rs._______________________p.a.

4. Income from land Properties Rs._______________________p.a.
5. Income from Investment in Bank/ Post Office etc Rs._______________________p.a.
6. Income from Share Certificate/ Debentures Rs._______________________p.a.
7. Income from any other sources
(i.e. Retirement Benefits for VRS/ VSS etc. if any) Rs._______________________p.a.

(B) Income of my wife/ husband (if any) Rs._______________________p.a.

(if employed salary certificate employer / Form 16 to be enclosed)

(C) Income in the name of my son/ daughter Rs._______________________p.a.

GROSS TOTAL INCOME (A+B+C) Rs._______________________p.a.

Further I declare that the information given above is true. I understand that the Merit-cum Means
Scholarship/Freeship/Free Messing/Scholarship, if awarded to my son/ daughter, is liable to be withheld 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 been
granted any other Scholarship/ Stipend/ Fin. Assistance etc. by any Govt./ Non-govt. organisation for the
same period, I shall be bound to refund the whole amount of Scholarship / Stipend/ Financial Assistance etc.
to the scholarship awarding authority immediately. I shall also be personally held responsible for the refund of
the Scholarships amount (paid to my son/ daughter by the Institute) in the event of any information in this
declaration being found incorrect/ false later on.
_________________________
(Signature of Father/Guardian)

Sworn before me this _________________ day of ____________________ 201_ and signed.

(SEAL with date) _______________________________________

Signature of First Class Magistrate/ S.D.O./B.D.O./ TEHSILDAR
or any other Revenue officer of the district of the signatory.
************
Note: The students are advised to keep a photocopy of the Income Certificate submitted at IIT Delhi for future reference.
 Form H-1
(PG)
INDIAN INSTITUTE OF TECHNOLOGY DELHI

UNDERTAKING BY THE STUDENT

(Only for Hostel Residents - To be submitted to the Caretaker of the Hostel)

I, Name ____________________________________________________________

Entry No. _____________________ and resident of _________________________

hostel hereby authorize Dean, Student Affairs/Warden to debit my Hostel Mess Dues

directly from my Savings Bank (SB) Account which is maintained in STATE BANK

OF INDIA(SBI), as and when the same is due. I shall maintain sufficient balance in

my SB Account for debiting the Hostel Mess Dues directly from my SB Account.

Signature of the Student: _______________________________

Name:_______________________________________________

Entry No. ____________________________________________

Date: ____________
 Form H-2
(PG)
INDIAN INSTITUTE OF TECHNOLOGY DELHI

Undertakings by the Parents and Student

(ONLY FOR FULL TIME STUDENTS)

1.Undertaking of awareness of medical facilities at IIT Delhi Hospital by Parent/Guardian

I....father/mother/guardian of
Mr./Ms..Entry No.. hereby declare the following
in respect of my ward to be admitted to B.Tech./ Dual degree programme of study at IIT Delhi.

I am aware of the following facts:

(i) The IIT Delhi Hospital located in the campus and run by IIT Delhi for its community has
limited facilities.
(ii) The IIT Delhi Hospital may not be adequate for treatment of a patient with chronic or serious
ailments.
(iii) It is the responsibility of the guardians to take care of their wards for outside IIT Delhi
treatment.
(iv) Each student would be provided a limited health insurance through a professional company.
However, the dealing with that company would be entirely the responsibility of the student. IIT
Delhi in no way would be responsible for any dispute/discrepancy.

Despite the best efforts on the part of IIT Delhi if any untoward thing happens to my ward,
I shall not hold the Institute accountable for the same and will not seek any financial help
or compensation for the same from any court of law.

Date: Signature of Parent/Guardian

2. Undertaking by the student for not owning and/or using motor driven vehicles on IIT
Delhi campus (for Hostel residents only):

Ison/daughter/ward of Mr./Ms. Entry

No hereby give an undertaking that I will not own/drive motor driven vehicle
on campus during my stay at IIT Delhi. If at any stage I am found to violate the above
undertaking my hostel seat will stand automatically cancelled without assigning any reasons.
I also undertake that any visitor bringing a vehicle would follow guidelines for registering the
vehicle at the hostel security and I would be liable for punishment for any violation on this
account

Date: Counter Signature of the Parent/Guardian Signature of the Student

********
 Form H-3
(PG)
INDIAN INSTITUTE OF TECHNOLOGY DELHI

Undertaking from the students as per the provisions of

Anti-ragging verdict by the Honble Supreme Court

I,..... Entry No...

Programme..Department....

as Student of Indian Institute of Technology Delhi do hereby undertake on this

day .month year. the following with respect to above

subject and Honble Supreme Court Order No. (available at http://dos.iitd.ac.in/antiragging.php ).

1) That I have read and understood the directives of the Honble Supreme Court of India on
Anti-ragging and the measures proposed to be taken in the above references.

2) That I understood the meaning of Ragging and know that the Ragging in any form is a
punishable offence and the same is banned by the Court of Law.

3) That (a) I have/ (b) I have not been found or charged for my involvement in any kind of
ragging in the past. In case of (a), I will inform in writing to the Dean of Students before
registration. In case of (b), I undertake to face disciplinary action/ legal proceedings including
expulsion from the Institute if the above statement is found to be untrue or the facts are
concealed, at any stage in future.

4) That I shall not resort to ragging in any form at any place and shall abide by the rules/ laws
prescribed by the Courts, Govt. of India and the Institute authorities for the purposes from
time to time.

..
Signature of Student

Name.

I hereby fully endorse the undertaking made by my Son/Daughter/ward.

Witness: ..
Signature of Mother/ Father and/ Guardian

....

**********