AFFIDAVIT I, CHIPPADA ANANTA RAO, S/o. Late Kuramayya, Hindu, male aged about 46 years, Caste by Telukali (B.C.

B), Labour, Dattivalasa Village, Naguru Post, Garugubilli Mandal, Vizianagaram District do hereby solemnly affirm on oath follows : I am a permanent resident menjtioned in the above address along with my family. I belong to Telukali (B.C. - B). I was granted house hold card Bearing No. YAP020500500170(Profession) Labour and getting Rs. 40,000/- (Rupees Forty Thousand Only) per annum from all sources as mentioned below except. I further state that my Son name is CHIPPADA PARASURAM, Aged 22 Years is studying Degree (B.Com.) 3rd Year with Roll No.________________, Bhaskar Degree College at Parvathipuram, Vizianagaram District for his Scholarship Fee reimbursement for while I was directed to submit this income declaration as per G.O.R.No.1307, dated 13-09-2010 is issued by the Govt. of A.P. The details mentioned in the above declaration specified in the G.O., are as follows. The above all facts are true and correct to the best of my knowledge belief and information. DEPONENT

Solemnly affirm and signed at__________________on_________________

before NOTARY

me

INCOME DECLARATION FORM

Name of the Student : CHIPPADA PARASURAM 1. (i) Name of the Father (ii) Whether Employed (iii) If employed, Designation (iv) Salary per month 2. (i) Name of the Mother (ii) Whether Employed (iii) if employed, Designation (iv) Salary per month 3. Agricultural holding of the parents mention extent (i) In the name of the father (ii) In the name of the Mother (a) Crops Grown in land (b) Whether Dry or Wet Land Annual income from Agricultural Land 4. Business mention the trade/name of business Income derived from the Venture 5. (i) No. of Vehicles owned by the family (ii) Whether used for personal/private use only (iii) Mention type of vehicles (two wheeler/three / four wheeler 6. (i) Type of House : Mention whether RCC, Thatched/ Tiled Roofed (ii) Mention whether Indiramma House (iii) Cost of Construction of House (iv) Whether constructed with loan, if so amount and Bank Branch (v) Any other type of house 7. (i) Whether living in own house or rented house (ii) if rented, mention rent amount 8. Telephone / Mobile Number 9. Total Family income from all sources ANANTA RAO NIL NIL NIL SAVITRAMMA - No Not Applicable NIL NIL NIL NIL NIL NIL NIL NIL Rs. 40,000/NIL

NIL R.C.C. Slabed House NIL NIL NIL NIL Own NIL NIL Rs. 40,000/Thousand Only)

Forty

I shall be liable for penal action both civil and criminal if the above facts found false in future besides recovery of the scholarship with the penal interest under RR act therefore, I request the concerned revenue authorities may be pleased to accept this

affidavit and issue income certificate to my Son CHIPPADA PARASURAM for scholarship / fee reimbursement purpose. The above all facts are true and correct to the best of may knowledge belief and information. Solemnly affirm and signed before me at________________on_____________ Name & Signature of the Student the Parent Date: Place: Name & Signature of Date: Place: