Application form for Central Sector Scholarship Scheme

(Govt. of India)

1. Name of Applicant : Self Attested

*2. (i) Institute Roll No. : Passport size
(ii) Hall & Room No. : Photo
(iii) SBI A/c No:
3. E-mail Address :
4. Mobile No. (if any) :
5. a. Name of Father :
b. Name of Mother :
c. SC ST
d. Name of Present Guardian :
(his relationship with the student
if parents are not alive)
e. Name of Brothers and their occupation:

f. Name of Sisters and their occupation:

6. Present Postal Address of Father/Guardian :

ANNUAL INCOME OF FAMILY

7. i) Fathers Gross Annual Income : Rs.

ii) Mothers Gross Annual Income (if any) : Rs.

iii) Annual Income from other source : Rs.

(i.e. Investment in Bank/ Post Office/UTI/LIC/ Share/Debenture/
Landed property/ Income in the name of student, etc., if any)

Total of 7 (i) +(ii) +(iii) above : Rs:______________

Contd2
8. Fathers/Guardians Occupational Status (Tick as applicable)

i) In Service (Govt./Pvt.): Form A is enclosed

(Supported by IT Form16 / Saral Form whose Annual Income
Is above Rs.1,10,000/-)
ii) Other than Salaried/Pensioner : Form B is enclosed
(Supported by Annual Income Certificate to be issued by
S.D.O./B.D.O./M.R.O./TAHASILDER/Local Municipal
Corporation/ Gram Panchayet, etc

If Businessman/Medical/Legal Practitioner/Consultant etc.:

a. Name & Address of Firm / Organisation / Shop :

b. Nature of Business/Trade :
c. Trade/Professional License/Registration No. :
(Copy to be enclosed)
d. Sales Tax /Comml.Tax Registration No./Zone :
iii) Pensioners/Family Pensioners : Form Cis enclosed
(supported by Non-Employment Certificate to be issued by :
S.D.O./B.D.O./M.R.O./TAHASILDER/Local Municipal
Corporation /Gram Panchayet, etc.)

9. Mothers occupation :
(with Address of Employer, if employed)

10. Declaration :

I declare the following:

i) No disciplinary action has been taken against me by the Institute in the preceding
session 2006-07.
ii) I am not in receipt of any other Scholarship/Stipend /Fin. Assistance, etc. from any
other source.

signature of the father/ signature of the student

guardian with date with date

Encl. :
1. Attested copy of 10 & 12 Certificate
2. Income Certificate
3. Proof of Permanent Residence
4. Cast Certificate

* Keep it blank
 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:

2. Certified that ____________________________________________ is employed in this
Organisation in the capacity of (Designation / post held by the
Employee)_______________________________, and that the break-up of his/her Gross Annual
Income from Salary received in the Financial Year_____________ is as follows:

Item Total Amount for 12 months

i) Basic Pay: Rs.

ii) D/Pay: Rs.
iii) DA/ADA/Relief: Rs.
iv) Special Pay & Honorarium, Bonus, etc., if any: Rs.
v) Other Allowances if any: Rs.

Total Rs.:________________

Employers Signature :

Designation:
Date :

(Official Seal)

N.B. : All the entries as stated in Column 2 above must be supported by attested copy of IT Form 16
/ SARAL Form for the corresponding year.
Guardians whose annual gross income is below Rs.1,10,000/- need not submit IT Return. They have
to submit a certificate from Employer / Salary disbursing officer stating that their annual income is
Not Taxable and they need not produce IT Form 16.

Contd2
 :2:

PART II

Income from other sources

(Declaration by the Father / Guardian of the Student)

I declare that my familys Annual Income from other sources during the Financial Year
____________________ was as follows :

Income from :

a. Landed Properties: Rs.

(Certificate from Tahsilder/Gram Panchayat)

b. Agriculture: Rs.

c. Investment in Bank/Post Office/Unit Trust etc.: Rs.

d. Share Certificates/Debentures: Rs.

e. Other sources: Rs.

Total: Rs.

Further I declare that the information given above is true. I understand that the Central Sector
Scholarship for SC Students if awarded to my son/daughter, is liable to be withheld or
discontinued at the discretion of the authorities of the PDPM Indian Institute of Information
Technology, Design and Manufacturing Jabalpur, without assigning any reason. If subsequently
it is found that he/she has been granted any other Scholarship/Stipend /Fin. Assistance, etc.
by any Govt./Non-govt. organization for the same period, I shall be bound to refund the whole
amount of Scholarship/Free ship/Stipend/Financial Assistance, etc. to the scholarship awarding
authority immediately.

I shall also be personally held responsible for the refund of the Scholarship/Free ship amount
(paid to my son/daughter by the Institute) in the event of any information in this declaration and also
in the enclosed scholarship application form, being proved
Incorrect later on.

Date :

Signature of the Father /Guardian:

Full Name:

Address with Pin Code:

Phone No., if any:

 FORM B

Format of Income Affidavit

(For use of those Parents/Guardians who are not in employment anywhere and derives income
from sources other than Salary/Pension)

(To be submitted on Non-Judicial Stamp paper of Rs.20/- and sworn in before a First Class
Magistrate/Notary Public)

I, Shri/Smt.__________________________ a resident of _______________________solemnly

declare that :

1. My son/daughter, Shri/Miss ______________________________ is currently studying at the

PDPM Indian Institute of Information Technology, Design and Manufacturing Jabalpur, in 4-
year B.Tech Program in ____________________________________Engineeing.

2. He/She is an applicant for the award of Central Sector Scholarship for SC Students
Scholarship for the Academic Year ________________.

3. I declare that my spouse is employed / not employed and that the Annual Income of my family in
the Financial Year____________ i.e. during the period from 1st April, _______to 31st March,
_______ was as mentioned hereunder (Supported by document) :

(A) From my own profession as indicated : Rs. _____________ p.a.

i) Income from Business/Medical practice
Legal Practice/Engineering Consultancy etc.
ii) Income from Agriculture Rs._____________ p.a.
iii) Income from Landed Properties Rs._____________ p.a.
iv) Income from Investment in Bank/ Rs. ____________ p.a.
Post Office etc.
v) Income from Share Certificates/Debentures Rs._____________ p.a.
vi) Income from any other sources(i.e. Retirement Rs. _____________ p.a.
Benefits for VRS/VSS etc., if any

(B) Income of my wife/ (if

Rs.___________
any) p.a. Rs. _____________ p.a.
(if employed, Salary certificate from Employer
to be enclosed)
.
(T) Income in the name of my son/ward (if any) Rs. _____________ p.a.
Contd2
Gross total Income (A+B+C) :-
 :2:
Further I declare that the information given above is true. I understand that the Central Sector
Scholarship for SC Students if awarded to my son/daughter, is liable to be withheld or
discontinued at the discretion of the authorities of the PDPM Indian Institute of Information
Technology, Design and Manufacturing Jabalpur, without assigning any reason. If subsequently
it is found that he/she has been granted any other Scholarship/Stipend /Fin. Assistance, etc.
by any Govt./Non-govt. organization for the same period, I shall be bound to refund the whole
amount of Scholarship/Free ship/Stipend/Financial Assistance, etc. to the scholarship awarding
authority immediately.

I shall also be personally held responsible for the refund of the Scholarship/Free ship amount
(paid to my son/daughter by the Institute) in the event of any information in this declaration and also
in the enclosed scholarship application form, being proved
Incorrect later on.

(Signature of Father/Guardian)

Sworn before me this _________________ day of ____________________ 200_____ and signed.

(SEAL)

Signature of First Class Magistrate /Notary Public