MODEL FORM OF DECLARATION OF INCOME IN THE FORM OF AFFIDAVIT (To be given by the Parents/Guardians in case of both salaried/non-salaried income) Whereas my son/daughter/dependent Shri/Kumari/Smt. a student

college/school has applied for grant of West

of

son of Shri

Bengal Govt. Merit-cum-Means Scholarship, I, Shri (Address)

do hereby declare that my total annual family income from all sources in the preceding year ending

March, 2015 is

Rs.

(in words also)

3lst

).

I make myself personally responsible for the accuracy of the facts and figures furnished.

I further declare that in the event of the particulars given in this declaration being found to be false I shall refund the whole amount of the scholarship paid to the said (Name of Student) and the Government decision whether the declaration of particulars is false shall be final and binding on me. Place

:

Date: (Signature in

Affirmed /Sworn before me

Signature of Notary Public/Ist Class Magistrate

Seal

full)

Identified by

MODEL FORM OF DECLARATION OF INCOME IN THE FORM OF ...

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