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FORM 'C

SPECIMEN COP)Y

Please Note; In case the following income affidavit is not provided by the concemes
Department. Please provide the Income certuficate issUed by oepatments duhy
signed and stamped by MAGISTRATE/ S.D.O./ B.D.O./ TEHSILDAR/
REVENUE OFFICER OF HIS / HER JURISDICTION.

INCOMEDECLARATIONN
INCOME DECLARATiON The declaration of the Gross Annual family Income s must for
declaration of family income from all sources. Affidavit should be on a Non-Judicial Stamp
for Rs.20/: or Rs.50/- sworn in before a First Class Magistrate/ S.D.O./B.D.O/TEHSTLDA
or any other Revenue Officer of the District of residence. Affidavit signed by Notary/0ath
commissioner will NOT be accepted.

For this purpose an affidavit is to be submitted by the Parent[s) whether baving cam
in service with Private/ Government organisation. The format is
business/ employment or

enclosed.

Name of Student:

Name ofthe Programme:(B.Tech.in Chemical Engineering


L Deepak Kumar, father/mother/guardian of Mr. Ms Gauransh KarmarEntn N
2019CHB1333), declare that my/our annual income from ali sources eg riE
agricultural/ trading/ pension/ interest/ m SpeciD allopes ofother

sOurces) including that ofmy spouse and unmarried children is Rs Iwo Lack
Thin Fr
Thousand Five Hundred Sixtv (Rupees 2.355601- onlv). The details are as follanS
(A)
1. From my profession/ Salary/ pension asindicated
Rs 235560-pa
(Attach proof from emplover/ Form 16/T RenumeLc.)

2.Income from Business/ Medical Consultancy etc. Rs 0 pa


Practice Legal Practice/ Engineering
Rs.0 p.a
3. Incomefrom Agriculture
Rs. 0 p.a
4.Jncome from landed Properties
Bank/ Pos1 Ofice eic. Rs. pa
5. Income from Investmentin
Rs, Op.
6. Income from Share Certificale/ Debentures
7.Income lrom any other sources Rs. 0p.a.
(i.e. Retirement Benclits lor VRS/ VSS etc. if
any)

Rs. Op.a,
B)Inconne ofmy wife/ husband ifany)
(Ifemploved salary certificate employer/
Form 16 to beenclosed)
Rs. 0 p.a.
ward (ifany)
C) Incomeinthename ofmy son/

that the
Further I declare
Rs 2,35,560 p.a.
INCOME (A) + (B) +(C) Free
GROSS TOTAL Means Scholarship/
Merit-cum
I understand that the
above is true.
information given is liable to be
to my son/ daughter,
Free messing/
Fee Waiver if awarded Indian Institute of
Studentship / authorities of the
discontinued at the
discretion of the award of
withheldor
reason. If subsequently (after
without assigning any other
Technology, Ropar has been granted any
it is found that he/she
fee waiver to my ward) for the
Scholarship / Govt/ Non-govt.
organization
Assistance etc. by any
Fin. Studentship/
Scholarship/ Stipend/ of Scholarship /Free
the whole a m o u n t
bound to refund immediately.I
same period, I shall awarding authority
scholarship
Assistance etc. to the son/
to my
the a m o u n t (paid
Financial
stipend/ the refund of
held responsible for declaration

shall also be
personally false in this
information found
in the e v e n t of any
the Institute)
daughter by
later on.

LTI
Qoepak
p

(Signature of Father/Mother)

2020 and signed.


this.
day of
Sworn before me

(SEAL with date)


Signature of First Class Magistrate/ S.D.0./B.D.O./ TEHSILDAR or any other Revenue

officer of the District of his/her Jurisdiction.


31-2

TEGaR

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