Meeseva Revenue Income Feereimbursement Application Form

Meeseva Revenue Income Feereimbursement Application Form

I, ___________________________________, S/o, W/o, Sri _______________________
_____________________________ aged about
years having an occupation of ______________________ resident of ______ D. No
__________________________ Locality\Landmark ________________________
Village / town ___________________ ______________ Mandal ______________
District ______________ Pincode do hereby solemnly
affirm and state on oath as follows.

I am the deponent herein as such I am well acq
uainted with the facts of this affidavit. I submit that I am the resident of above address, I am doing _______________________
(Profession) and getting Rs.__________________ in Rupees ____________________
___________ only per annum from all sources mentioned below except the above said
income. I belong to ____________ Caste, which comes under SC/ST/BC/Others. The
income certificate is necessary for my Son / Daughter ___________________________
Who is studying____________________________________
_____ at _____________
He / she required income certificate for getting sc
holarship / Fee reimbursement, hence I
am giving this affidavit along with income declarat

(As per G.O., RT No.1307, Rev., (Ser.II) Dept., and Dt.13.9.2010)

1 Name of the student :
2 Date of Birth :
3 (i) Name of the Father :
(ii) Whether Employed :
(iii) If employed designation, if
not other profession :
(iv) Salary per month :
4 (i) Name of the Mother :
(ii) Whether Employed :
(iii) If employed, designation,
if not other profession :
(iv). Salary per month :
5 Agricultural holding of the
parents mention extent

(i) In the name of Father :
(ii) In the name of Mother :
(a) Crops grown in land :
(b) Whether Dry or wet land :

I Annual income from agricultural land :
6 Business mention the trade /
name of business Income
derived from the venture :
7 (i) Number of vehicles owned
by the family :
(ii) Whether used for personal /
private use only :
(iii) Mention type of vehicles (
two wheeler / three wheeler /
four wheeler) :
Regd No.
(iv) Vehicle registered on
whose name :
8 (i) Type of house mention
Whether RCC / thatched /
Tiled roofed :

(ii) Mentioned, whether
Indiramma House :
(iii) Cost construction of
House :
(iv) Whether constructed with
loan, if so amount and bank
Branch :
(v) Any other type of house :
9 (i)Whether living in own house
or rented house :
(ii) If rented, mention rent
amount :
10Telephone/Mobile Number :
11Total family income from all
sources :
12Ration Card Number :
13Aadhar Card Number :
14Email :
I shall be liable for penal action both civil
and criminal, if the above facts are false in
future besides recovery of the scholarship with pen
al interest under the revenue recovery
act. Therefore, I request the concerned revenue aut
horities may be pleased to accept this
affidavit and issue income certificate to my son/da
ughter _______________________
____________________________________for scholarship/fee reimbursement purpose.

The above facts are true and correct to the best of my knowledge and belief.

Name & signature of the student
Name & Signature of the Parent

Date: / /
20 .
Solemnly affirm and signed bef
ore me at on / /
Attested by:
Signature of the Notary

Procedure: (following to be enclosed)

1) Application Form*
2) Ration Card copy/EPIC CARD/AADAR CARD#
3) Copy of IT Returns/pay slip/Any other document#
mandatory #
any one of them