BOARD OF SCHOOL EDUCATION HARYANA, BHIWANI

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1 From BOARD OF SCHOOL EDUCATION HARYANA, BHIWANI CSSS-I To The Secretary, The Principal, Board of School Education Haryana, All Govt./Recognized Sr. Sec. Schools, Bhiwani Haryana. Ref. No. Spl-I/ Sr. Sec. / Scholar/March 13 Regd. Date: Sub: Central Sector Scheme of Scholarship for College / University Students Year Sir/Madam, This is regarding the National Scholarship Scheme of the Ministry of HRD, Govt. of India for those students who have secured 80 percentile and above marks in Sr. Sec. Certificate exam from this Board. The Scholarship award as per this policy will be given to eligible Rs.10,000/- per annum for three years upto graduation level and Rs. 20,000 per year for two year upto post graduation level. The students pursuing professional courses would get Rs. 2000/- per month in the 4 th & 5 th year. The Scholarship would be paid for 10 months in academic year. This Scholarship award will be given to only those students who are studying further as a regular degree courses/classes in a recognized Institute/College. Those Students Studying in Diploma/Certificate courses and through distance/correspondence mode will not be eligible. The income of parents/ guardian should not be in creamy layer as per extant of Govt. instructions. The case for renewal of scholarship award for next year will be considered only for those students who will secure minimum 60% marks or equivalent Grade point, Average in aggregate for two proceeding semester at the Annual Exam which determines his promotion to the next class in the said course/exam and complete the 75% attendance in the institute also. Complaints against the scholar regarding indiscipline including any complaints of having indulged in ragging would lead to forfeiture of scholarship. If a scholar gives up the chosen course of study before its completion or if he/she change the course of study without the approval of the Ministry of HRD the scholarship will be cancelled. Good conduct & regularity in attendance as mentioned above are also required for continuance of the scholarship. Other conditions for eligibility will have to be fulfilled as laid down and instruction issued from time to time by the Ministry of HRD, New Delhi. The from CSSS-I along with Annexure I to IV for all such students who have secured 80 percentile and above marks in above exam of your school are being sent herewith to you with request to hand over this Scholarship From to the concerned student immediately, so that he/she can submit it in this office after completing all the requisite formalities, documents. The complete from in all respects must be received in the O/o Assistant Secretary (Sr. Sec. Scholarship) Board of School Education Haryana, Hansi Road, Bhiwani upto (5.00 PM) by hand/regd. Post Incomplete application from or received after the prescribed last date will not be entertained. The decision of the Ministry of HRD, New Delhi will be final & binding in all such matters. The scholarship once cancelled will not be revived under any circumstances. The particulars shown in application from & bio-data summary (Annexure-IV) should be the same. Yours Sincerely, Note:- Encl. CSSS-I Performa (with Annexure I to IV) Asstt. Secy. (Sr. Sec. Scholarship) For Secretary

2 CSSS-I BOARD OF SCHOOL EDUCATION HARYANA, BHIWANI GOVERNMENT OF INDIA MINISTRY OF HUMAN RESOURCE DEVELOPMENT DEPARTMENT OF HIGHER EDUCATION APPLICATION FORM FOR SCHOLARSHIP AWARD UNDER CENTRAL SECTOR SCHEME OF SCHOLARSHIP FOR COLLEGE AND UNIVERSITY STUDENTS YEAR-2013 Sr. No Merit No. Stream: Art/Commerce/Science Rural/Urban LAST DATE FOR SUBMISSION OF APPLICATION :- 31 st August 2013 NOTE: - Statement of Particular, Income Affidavit, Joining report and Bio-Data Proforma duly filled in should be handed over to the Head of the Institution, Where the student has joined under Graduation course. The Head of the Institution-will-forward-it; to the Assistant Secretary (Sr. Sec. Scholarship):- Board of School Education Haryana, Hansi Road, Bhiwani after attestation of Photo and joining report. All the Annexures should be read carefully before the form is filled. No change will be permitted after it has been submitted. If any entry is found incorrect the scholarship, if awarded, is liable to be cancelled forthwith. Incomplete application form or receive after the prescribed last date will not be considered. Student may ensure that the complete form is forwarded by the Head of the Institution well in time. The Photo and Joining Report must be attested by the same competent authority. 1. Name of the Candidate (in block letters) (As Per Class XII Certificate) 2. Date of Birth (As per Class X Certificate) 3. Sex: Male / Female (Tick) MALE FEMALE 4. Category: (Pl. attach proof) (Tick) General/SC/BCA/BCB/Handicapped 5. Details of Father/ Guardian/ Husband as the case may be a. Father s Name b. Permanent Home address Pin Code- c. Profession and office address of parents Pin Code- 6. Details of Communication a. Address for correspondence (institution) b. Telephone No. With STD Code Pin Code- c. Mobile No. d. E- Mail ID

3 7. Is father/guardian/husband a citizen of YES/NO India: 8. Name of Present studying College/Instt. 9. a) Name of Course. a) Degree Diploma b) Mode of Course.. b) Regular Distance Corres- Pondance 10. College/Institute Roll No. 11. Date of admission in Collage /Class 12. Details of Class XII Examination passed by the candidate in March 2013 a. Name of the Examination passed b. Roll No. c. Total aggregate marks and percentage obtained in the examination 13. Is the candidate in receipt of any other scholarship form State Government or other Institute of person (/Tick), if yes, give the name and amount of the scholarship. 14. Particulars of Saving Bank Account of the candidate. The bank account should be opened in the banks which have online transaction facility only. 15. Unique Identity (Adhaar Card No.) 16. Bank Detail :- a Name and Address of the Bank b Account Number c Bank Code Number d RTGS:NEFT:IFSC:No.11digit Code of the Bank [Check with your Bank] Marks % of marks YES NO Amount... The Scholarship give by.. IFSC NO.. (MOST COMPULSORY) 17. List of enclosures sent with this application (without enclosures application will not be considered) a b c d e Income Affidavit (should be as per prescribed specimen only) Attested copy of Marks Sheet of Senior Secondary Certificate Examination Attested copy of Caste Certificate (SC,BCA/ BCB/Medical certificate of Handicapped) Attested Photo & Joining Repot (Should be attested by same authority) Salary certificate (Father/Mother both, Guardian if applicable) Certified that all the information given in this form are true correct to the best of my knowledge. I declare that in case I am selected for this scholarship, I shall devote my full time to the course of study and that I shall not accept/receive any another stipend/scholarship from any other source. I undertake to maintain the bank A/c mentioned in column 14 till the completion of my studies. Place: Date: Signature of Candidate Mobile No. (FOR OFFICE USE ONLY) ELIGIBLE/NOT ELIGIBLE Asstt. Secretary (Sr. Sec.) Supdt. (Scholarship) Assistant (Scholarship)

4 BOARD OF SCHOOL EDUCATION HARYANA, BHIWANI GOVERNMENT OF INDIA MINISTRY OF HUMAN RESOURCE DEVELOPMENT DEPARTMENT OF HIGHER EDUCATION ANNEXURE-I CENTRAL SECTOR SCHEME OF SCHOLARSHIP FOR COLLEGE AND UNIVERSITY STUDENTS YEAR-2013 JOINING REPORT 1. This is to certify that is Shri/Smt/Kumari S/o,D/o,Shri/Smt. who has passed the Senior Secondary Certificate Examination held in March-2013 conducted by the Board of School Education Haryana, Bhiwani has been granted admission in this institution Recent colour Photograph be affixed of the scholar duly attested and stamped by the Principal of College/Institute where the student is presently studying. On the day of for the course. He/she started attending the classes w.e.f under Roll No. 2. The complete application from (CSSS-I), Income Affidavit (Annexure-II), Entitlement Card (Annexure-III) and the Bio-Data (Annexure-IV) are also enclosed. 3. He/she is studying in a regular course/study in this institute / college. This institute / college is recognized and affiliated to University. Principal, Seal of the Institution Telephone No. With STD Code Mob. No. Note: 1. The above joining report and candidate s Photo must be attested by the same Competent authority. 2. The Students studying in diploma/courses / distance / correspondence mode are not eligible for this scholarship scheme. The scholarship form of such students should not be attested by any authority, 3. If a student is getting any other scholarship the joining report of such student should not be attested. To The Assistant Secretary (Sr. Sec. Scholarship), Board of School Education Haryana, Bhiwani

5 SPECIMEN OF INCOME AFFIDAVIT ANNEXURE -II Declaration of income of Parents/Guardian for the year (ending on 31 st March 2014) {enter relevant year} for the purpose of scholarships granted under the Central Sector Scheme of Scholarship for College and University Students I (Name of Parents/Guardian/Husband) Son/daughter of Shri/Smt. presently residing at solemnly affirm and say as Follows:- 1. That my son/daughter/dependent Shri/Kumari who has been provisionally selected for Scholarship award under the Central Sector Scheme of Scholarship for College and University Students, is studying in (Here giving the name of Institution / College with course name) 2. That my annual income in the proceeding year ending the 31 st March, 2014 is as per Rs. Details furnished in the schedule here under written, I also affirm that particulars of property held by me is as shown in the schedule. I personally responsible for the accuracy of the facts and figure furnished by me. 3. That my son/daughter is getting other scholarship Rs. per annum/one time. 4. That my son/daughter is not getting any other scholarship for this study course. (out of Sr. No. 3 & 4 please choose one, which is applicable) 5. That the statements made in the foregoing paragraphs are true to my knowledge. 6. That I further undertake that in the event of the particulars given in this declaration being found false, I shall refund to the President of India DOUBLE the amount of the scholarship given to the said scholars (s) and the Government s decision on whether the declaration of particular is false shall be final and binding on me. Sr. No. Source of Income Amount 1. Income from agriculture land Rs. 2. Income from property held (House, shop, Building. Site, Rents etc.) Rs. 3. Income from shops/business Rs. 4. Income from salary be Self/Spouse (Mother/Father) 5. Income of wife/husband of the scholar if married Rs. Rs. 6 Income from Industry, Factory etc. Rs. 7. Income from Daily Wages/Majdoori/ Part time occupation etc. Court Stamp Must be Affix Rs. 8. Total income 1 to 7 Rs. I also declare that my income from all sources is not in creamy layer level. Date : Deponent Verification: Verified that the above statement is true and correct to the best of my knowledge and belief and nothing has been concealed therein. Deponent

6 P.T.O. Note : 1. To be signed in the presences of Notary Public or Magistrate/1 st Class Magistrate Executive/ Revenue Officer/Who would also Affix his signature, seal and court stamp. 2. The affidavit must be given as per above Specimen otherwise your application will be rejected. 3. Total income of the family should include income only of father & mother of scholar and of no other members though they may be earning. 4. If father is dead, mother s income will be shown along with the income, if any, in the scholar own name from shares, property etc. 5. If both Father and Mother of the scholar are deceased, the income, if any in the scholar s name only will be shown and not the income of the guardian who may be supporting the scholar. 6. Income for the purpose of mean test is defined as under:- (a) In the case of salaries class, basic pay plus income if any from other sources and would not include allowance like Dearness Allowance, City compensatory allowance etc. (b) In case of income from source liable to income tax, income computed (after deduction for rebateable items) for the purpose of assessment of income tax, as per income tax Ruler for the year. (c) In the case of income not liable to income tax, such as income from Agriculture etc. the net income that is arrived at after deduction expenditure incurred for earning that income.

7 Merit No. / / 2013 (For office use only) ANNEXURE-III BOARD OF SCHOOL EDUCATION HARYANA BHIWANI SCHOLARSHIP ENTITLEMENT CARD GOVERNMENT OF INDIA MINISTRY OF HUMAN RESOURCE DEVELOPMENT DEPARTMENT OF HIGHER EDUCATION SCHEME OF SCHOLARSHIP FOR COLLEGE AND UNIVERSITY STUDENTS Sh./Smt./Ku. S/o/D/o Sh. has been selected for an award under the above mentioned scheme on the basis of result of Sr. Sec. Examination held by this Board in March He/ She obtained marks out of 500 marks and secured the rank in the merit. Now he/she is studying in Latest Photograph of Scholar be affixed and attested by Head of Present College/Institute Dy. Secretary, (Exam) Board of School Education Haryana, Bhiwani (Signature of Scholar)

8 ANNEXURE-IV BOARD OF SCHOOL EDUCATION HARYANA,BHIWANI CENTRAL SECTOR SCHEME OF SCHOLARSHIP FOR COLLEGE & UNIVERSITY STUDENTS SENIOR SECONDARY CERTIFICATE EXAMINATION, MARCH 2013 BIO DATA STREAM: ART/COMMERCE/SCIENCE CATEGORY: SC/BCA/BCB/GERNAL/PH STREAM CATEGORY MERIT No. ROLL No. (Sr. Sec.) MARKS OBTAINED & PASS % 1. NAME OF THE STUDENT 2. FATHER S NAME 3. SEX : MALE / FEMALE 4. PERMANENT POST ADDRESS 5. NAME OF PRESENT INSTITUTION/COLLEGE ADDRESS 6. NAME OF COURSE & COLLEGE ROLL NO. 7 MODE OF EDUCATION / COURSE 8. COURSE (DEGREE / DIPLOMA) 9. PARENTS ANNUAL INCOME (AS PER AFFIDAVIT) 10. BANK NAME & ADDRESS (a) BANK CODE (b) BANK ACCOUNT NO. (c) IFSC CODE/MICR NO. (d) BANKING ACCOUNT NO. 11. STUDENT S ADDRESS 12. UID (Aadhaar Card No.) (SIGNATURE OF CANDIDATE) MOB. NO PLACE:- DATE:-

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