PDPM

Indian Institute of Information Technology,

Design & Manufacturing, Jabalpur

Application form for MCM Scholarship and Freeship

1. Name of Applicant :
2. Category : (GE/SC/ST)
3. (i) Institute Roll No. :
(ii) Hall & Room No. :
(iii) SBI A/c No:
4. E-mail Address & Mobile No. (if any) :
5. a. Name of Father :
b. Name of Mother :

c. Name of Present Guardian :

(his relationship with the student
if parents are not alive)
d. Name of Brothers and their occupation:

e. Name of Sisters and their occupation:

6. Present Postal Address of Father/Guardian :

ANNUAL INCOME OF FAMILY

7. i) Father’s Gross Annual Income : Rs.

ii) Mother’s 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:______________

Contd…2
8. Father’s/Guardian’s 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.50,000/-)
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 ‘C’ is 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. Mother’s 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 2007-08.
ii) I am not in receipt of any other Scholarship/Stipend /Fin. Assistance, etc. from any
other source.

Encl. :

signature of the father/ signature of the student

guardian with date with date
 Annexure : II

List of Documents to be Submitted

Following documents are required to be submitted along with MCM scholarship application for 2008-
09 for different Classes of Occupational Status

1. For Salaried Class (Parent’s/Guardians’ who are in Service either Govt. or Private)
a. Salary Certificate for the Financial Year 2007-08 (from 01.04.07 to 31.03.08) in prescribed
Form ‘A, given in Annexure III (available on Web page or in academic section) duly
sealed/stamped by the Salary Disbursing Officer.

b. Copy of IT Form 16 to be issued by employer or attested copy of SARAL Form to be duly

stamped / sealed from concerned Income Tax Office, as applicable, for the year 2007-08
(Assessment Year 2008-09).

2. For Non-Salaried Class (Parent’s/Guardian’s who are not in Service such as Businessmen, Legal
/Medical Practitioners, Consultants, Private Tutors, Retired without Pension/Self-employed
persons etc.).
a. An Annual Income Affidavit for the financial year 2007-08 in a Non-Judicial Stamp for
Rs.20/- sworn in before preferably a First Class Magistrate / Notary Public as per the
format given in Form “B” Annexure IV (available on Web page or in academic section).
b. An Income Certificate from local District Authorities, like S.D.O. /B.D.O. /M.R.O.
/TAHASILDER /Local Municipal Corporation /Gram Panchayet, etc. in addition to Income
Affidavit and other documents as stated above and below.
c. Attested copies of SARAL Form / IT Return, as applicable (to be attested by a Gazetted
Officer), for the year 2007-08 (Assessment Year 2008-09) duly stamped / sealed from
concerned Income Tax Office.
d. Attested copies of Trade / Professional License, Sales /Comml.Tax Registration Certificate
to be issued by the competent authority if applicable.
Copy of Registration Certificate must be submitted in case of Medical Practitioner and
Legal Practitioner.
e. Incase of Agriculture income below Rs.50,000/-, they need not submit Income Tax
documents but they have to submit an Income Certificate from local District Authorities like
S.D.O./B.D.O./M.R.O./TAHASILDER, Local Municipal Corporation, etc. in addition to
Annual Income Affidavit as stated in section 2(a) above.

3. For Pensioners/Family Pensioners

a. Annual Pension Payment Certificate for the year 2007-08 in prescribed Form ‘C’ given in
Annexure V (available on Web page or in academic section) to be issued by the Pension
Disbursing Officer.
b. An Income and Non-employment Certificate from local District Authorities like S.D.O. /
B.D.O. /M.R.O./TAHASILDER, Local Municipal Corporation/Gram Panchayet, etc. also to
be submitted in addition to other documents as stated in section 3(a) above. In case of
Pension Income below Rs.50,000/-, they need not submit Income Tax documents.
 Annexure : III

FORM - A

Annual Income Certificate for those Parent’s/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.:________________

Employer’s 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.50,000/- 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.

Contd…2
 :2:

PART – II

Income from other sources

(Declaration by the Father / Guardian of the Student)

I declare that my family’s 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 Merit-cum-Means
Scholarship/Freeship 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 (after award of MCM
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. 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:

 Annexure :IV

FORM – B

Format of Income Affidavit

(For use of those Parent’s/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 Merit-cum-Means 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)
.
(C) Income in the name of my son/ward (if any) Rs. _____________ p.a.
Contd…2
Gross total Income (A+B+C) :-
 :2:

Further, I declare that the information given above is true. I understand that the Merit-cum-
Means Scholarship 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 (after award of MCM 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. organization for the same period, I shall be bound to refund the
whole amount of Scholarship/Freeship/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

 Annexure : V

FORM – C

(For Pensioner/Family Pensioner only)

(Income /Salary Certificate for those Parents/Guardians who are in pensioners or retired from
service or their wives are getting family pension)

PART - I

Income from Pension / Family Pension : Rs.

1.Name and Address of the Ex-Employer with P.P.O. No.

2.Certified that __________________________________________________ was employed in

this Organization/superannuated from, in the capacity
of__________________________(post held by the retired employee) and that the break-up of
his/her Annual Income from Pension/Family Pension received in the financial
year____________ is as follows :

Item Total Amount for 12 months

i) Basic Pension / Family Pension: Rs.

ii) Dearness Relief: Rs.
iii) Other Allowances, if any: Rs.

Total Rs.:________________

Signature of Ex-Employer/
Pension Disbursing Officer: _______________________
Designation: ______________________________
Date:

(Official Stamp)
 :2:

PART – II

Income from other sources

(Declaration by the Father / Guardian of the Student)

I declare that my family’s 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 Merit-cum-Means
Scholarship/Freeship 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 (after award of MCM
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. 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:

N.B. : Pensioners Annual Income below Rs. 50, 000/- need not submit Income Tax documents
but they have to submit an Income & Non-Employment Certificate from local District Authorities
like S.D.O. / B.D.O./M.R.O./ TAHASILDER, Anchal Officer, Local Municipal Corporation, etc.. as
applicable.