Annexure 10

NEED BASED FINANCIAL ASSISTANCE (NBFA)

APPLICATION FORM, 2018-19

Documents to be Attached:
Please enclose the following documents along with the application:

1. For employed (salaried) person, following documents are required:

a. If annual income of the person is less than / equal to 3 Lakhs, certified copy of Income Tax
Return receipt (ITR-V) for FY 2017-18 (AY-2018-19) (preferable) OR Form-16 for FY 2017-18
(AY-2018-19) OR salary certificate from employer.
b. If annual income of the person is more than 3 Lakhs, Form-16 for FY 2017-18 (AY-2018-19)
AND certified copy of Income Tax Return receipt (ITR-V) for FY 2017-18 (AY 2018-19).

2. If the person is self-employed in business or in agriculture or in any other profession, following

documents are required:
a. If annual income of the person is less than /equal to 3 Lakhs, certified copy of Income Tax Return
receipt for FY 2017-18 (AY-2018-19) (preferable) OR Tahsildar’s certificate showing the total
income.
b. If annual income of the person is more than 3 Lakhs, certified copy of Income Tax Return receipt
for FY 2017-18 (AY 2018-19) (ITR-V).

3. If the person is retired, following documents are required:

a. If annual income of the person from the pension is less than 3 Lakhs, certified copy of Income
Tax Return receipt for FY: 2017-18 (AY-2018-19) (preferable) OR pension certificate from
employer.
b. If annual income of the person from the pension is more than 3 Lakhs, pension certificate from
employer AND certified copy of Income Tax Return receipt for FY 2017-18 (AY-2018-19).

What you should know before applying for Need-based Financial Assistance

 Applicant’s family income in FY 2017-18 will include applicant’s own income, income of his/her
parents, brothers (if not married) and sisters (if not married). In case any of the above persons does not
contribute to the family, applicant is requested to make an appeal with valid proof for the same.
 If a family member including the applicant has multiple sources of income, all sources of income
should be explicitly mentioned and valid proof should be given.
 To avail this financial assistance, the applicant MUST submit all required documents to the relevant
authority showing total family income in the financial year 2017-18 (Assessment year 2018-19). ITR-
V receipt of previous year (i.e., FY 2016-17) will not be accepted as a valid proof. Applicant’s family
member must submit ITR-V for FY 2017-18 if the document is required based on applicant’s
eligibility.
 Since need-based assistance is provided on the basis of the family income declared in the application
form for need-based financial assistance, the applicants are responsible for the veracity of the
information provided, and not the committee members who decide the list of eligible applicants. Any
discrepancies found regarding the declared income and the actual income that may come to the notice
of the committee in future will attract punitive action taken against the student concerned.
 In case of any discrepancy found in the information provided or non-disclosure of any information,
punitive action may be taken against the applicant along with the cancellation of the assistance
facility, and expulsion from the programme with immediate effect.

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 CHECK LIST OF DOCUMENTS ATTACHED (Add rows as required)

Name Relationship Annual Occupation Documents Attached as proof

with applicant Income
(Rs)
1 SELF
2 SELF (Summer
Internship, April-
June 2018)*
3
4
5
* Only for PGP 2s. PGP1s should mention N.A.

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 Indian Institute of Management Calcutta (IIMC)
Summary Sheet: Application for Need-based Financial Assistance, 2018-19

IIMC PGP Registration No. IIMC/PGP/PGDM/

/
1. Name in Block Letters
First Name Middle Name Last Name

2. Date of Birth / /
DD MM YYYY

3. CATEGORY General NC-OBC SC ST DA

4. Marital Status Single Married

1. Educational background:

School/College Location Dates Attended Degree/Diploma

2. If you have been employed in the past, list the jobs you have held:

Position & Name of the Organization Period Monthly Salary

From To Rs.

3. List all the members of your family, including the applicant, along with their annual incomes in FY: 2017-18 from
salary/pension/business

Name Age Relationship Annual Income Occupation IT Account No. (PAN No.)
with applicant (Rs) Ward / Circle /
Special Range
1. SELF
2.
3.
4.
5.
Total annual income of the family in FY 2017-18
from salary/pension/business

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 Indian Institute of Management Calcutta
Application for Need-based Financial Assistance, 2018-19 (Detailed Sheets)

Part I (To be filled in by the applicant)

 Please submit this form, duly filled in, along with Part II and the Income Declaration Form, to the PGP Office after
Registration and latest by August 23-24, 2018
 Applications received thereafter may not be considered.
 Incomplete applications will be rejected.
 Use additional sheets, if necessary.

IIMC PGP Registration No. IIMC/PGP/PGDM/

/
1. Name in Block Letters
First Name Middle Name Last Name

2. Date of Birth / /
DD MM YYYY

3. CATEGORY General NC-OBC SC ST DA

4. Present Address

5. Permanent Address

6. Contact Details:
Institute Email id

Mobile No.

Phone No.
CODE NUMBER

Fax. No.
CODE NUMBER

7. Educational background:
School/College Location Dates Attended Degree/Diploma

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 8. Marital Status Single Married

9. If you are married, please provide the following details:

a) Name of your spouse
b) Education qualification of your spouse
c) Is your employed at present?
d) If yes to ‘c)’ above, then what is his/her monthly salary (in Rs.)?

10. If you have been employed in the past, list the jobs you have held:

Period

Position & Name of the Organization From To Monthly Salary (Rs.)

11.
a) If you have been employed in the past, what is the amount of
your savings (in Rs.)?
b) Do you or your spouse/dependents own a house?
c) If yes, indicate its rental value (in Rs.)

12. Please state and list the value of all other assets you/your spouse hold, including vehicles, shares, bonds etc.

Name of Asset Value in Rs.

a.
b.
c.
d.
Total

13. Details about insurance carried on your own or your dependents’ lives.

Name of the Year in Face Value of Annual Approx. Amount of Present value after
insured which the the policy Premium Amount of loan deducting the
policy was (in Rs.) (in Rs.) premium paid as outstanding, if outstanding loan
taken to date any (in Rs.)
(in Rs.) (in Rs.)
a) Yours

b) Spouse’s

c) Other
Dependents

Total

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 14. Financial Requirements for the PGP at IIMC (Please indicate below how you have planned to finance your study at the
Institute)

A Estimated Expenditure for 2018-19

1. Educational Expenses (excluding refundable caution deposit) Rs. 10,51,630.00
2. Average Mess charges Rs. 60,000.00

3. Personal Expenses Rs.

Total of A

B Estimated Resources
Particulars

(a) Own contribution / savings Rs.

(b) Parents & other relatives Rs.

(c) Spouse’s contribution Rs.

(d) Other scholarships, if any Rs.

(e) Others, for example, loans (taken or proposed to be taken) Rs.

Please specify

Total of B
C Shortfall, if any (A-B), anticipated to be covered by IIMC’s Need-based Rs.
Financial Assistance

15. Please mention below any special, personal or financial circumstances which might have a direct bearing on your
application for financial assistance.

AFFIDAVIT

I certify that the above application truly represents my financial position and includes all my resources. Should there be any
significant change in my resources, I shall notify the Institute’s Financial Aid Committee immediately. If I get any other
scholarship/financial assistance/income, I undertake to refund the amount of financial assistance awarded by the Institute, if
required.

Date:
Signature of the Applicant

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 Indian Institute of Management Calcutta (IIMC)
Application for Need-based Financial Assistance, 2018-19

Part II: To be filled in and signed by the head of the household (father or mother or guardian of the applicant, henceforth
referred to as ‘parent’).
Note: This form is part of your ward’s application for financial aid at the Indian Institute of Management Calcutta. You are
requested to complete this form in every respect and attach the documents listed in Appendix I. The information you provide will
be treated as strictly confidential. The Financial Aid Committee will be able to consider your ward’s application only on receipt
of this form and the Income Declaration.

IIMC PGP Registration No. IIMC/PGP/PGDM/

/
Name of the Applicant
First Name Middle Name Last Name

1. Personal Information of Parent

a) Name of the Parent
b) Age (in completed years)
c) Highest educational qualification
d) Present Address

e) If in Service:
i. Your designation
ii. Gross annual salary (in Rs.)
iii. Nature of your job
iv. Address of employer
v. How long have you been serving
in this job (Note: if retired, give
details of last held job)
f) If in Service:
i. Nature of business (sole proprietor
/ partner)
ii. Products manufactured / sold
iii. Premises owned or rented
iv. No. of persons employed
v. Value of total assets
vi. Annual income from the business

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 2. List all the members of your family, including the applicant, along with their annual incomes in FY 2017-18 from
salary/pension/business
Name Age Relationship Annual Income Occupation PAN No.,
with applicant (in Rs.) Ward / Circle/
Special Range
1
2
3
4
5
Total annual income of the family in 2017-18 from
salary/pension/business

3. Financial Information of Parent (In answering the following, please provide specific figures in Rs.)
a) Your total income during last one year (2017-18) from all sources (including
salary/pension/business, rental income, income from investments, other income and a fair value of
perquisites received)
b) Total income from all sources of other earning members of the family, including the
applicant, living with you during 2017-18
c) Your estimated income for 2018-19
d) Estimated income of other members of the family living with you during 2018-19
e) Estimated contribution from other earning members not living with you during
2018-19
TOTAL of c+d+e

4. Principal Assets and Liabilities of Family

(a) Particulars of Life Insurance Policy

Name of the insured Year in Face Value Annual Approx. Amount of Present value
which the of the policy Premium Amount of loan after
policy was (in Rs.) (in Rs.) premium paid as outstanding, deducting the
taken of date if any outstanding
(in Rs.) (in Rs.) loan
(in Rs.)
i) Yours

ii) Spouse’s

iii) Other Dependents

Total

(b) Immovable Properties (House Property)

House property (Indicate place, location and Present sale value Unpaid mortgage Difference
complete address) (a) (b) (a-b)

Total

(c) Immovable Properties (Agricultural Lands)

Agricultural land, No. of acres (Indicate place, Present sale value of Unpaid mortgage Annual income from
location, wet/dry, etc.) land land

Total

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 (d) Immovable Properties (Other Real Estate properties) (value in Rs.)
Other real estate Present sale value of Unpaid mortgage Difference
the property (b) (b-a)
(a)

Total

(e) Other investments / assets (value in Rs.)

i) Capital value of your share of the business (if you are doing business)

ii) Market value of other investment, e.g. shares, bonds, vehicles, etc. (give details in Appendix I)

iii) Savings (current account / fixed deposits)

iv) Provident Fund

Total

5. Extent of Support to Ward (values in Rs.)

a) What was your total support per annum for the graduate education of your ward?
Please give details. (Attach additional sheet if necessary)
b) During the current academic year to what extent will you support your ward?
c) Assistance, gifts, educational insurance, from relatives, friends, or organizations
which can be expected/used by your ward towards expenses at IIMC
d) Any other source of help

e) Additional information or comments

TOTAL of c+d+e

Date:

Place:
Signature of the Parent of Applicant

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 Appendix I: Details towards 4(e) of PART II

i) Give details of shares owned by you in the following proforma:

Name of Company No. of shares Present Market Value (Rs.)

ii) Give details of fixed deposits / other financial investments owned by you in the following proforma:
Name of Company Date of Maturity Amount (Rs.)

iii) If you own a car, please provide its present resale value

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 IIMC PGP Registration No. IIMC/PGP/PGDM/
/
Name of the Applicant
First Name Middle Name Last Name

INCOME DECLARATION

Income declaration for the year ended 31st March 2018 for the purpose of Need-based Financial Assistance for the
Academic Year 2018-19 sought from Indian Institute of Management Calcutta.
Whereas my son/daughter/ward, Mr./Ms._________________________________________________ who has
applied for Need-based Financial Assistance has been offered admission to the Postgraduate Programme in
Management (PGDM)/ Postgraduate Programme in Computer Aided Management (PGDCM) at the Indian
Institute of Management Calcutta.
I, Shri/Smt. _______________________________________________________________________, a permanent
resident of
_______________________________________________________________________________________
_________________________________________________________declare that my family’s (including my
son’s/daughter’s/ward’s) Annual Gross Income from All Sources in the preceding year ended on 31st March
2018 is Rs. _______________ (Rupees_______________
___________________________________________________ only) as per details furnished in the Schedule. I
also affirm that particulars of property held by me are as shown in the Schedule and that I have correctly indicated
the amount of various taxes, cesses and land revenue paid by me. I make myself personally responsible for the
accuracy of the facts and figures furnished.

I further undertake that in the event of the particulars given in this declaration being found to be false, I shall
refund to the Indian Institute of Management Calcutta the amount of the Need-based Financial Assistance paid to
my son/daughter/ward, and the Director’s decision on whether the declaration of particulars is false shall be final
and binding on me.

Date: Place:

Name of Parent in Full Signature of the Parent

TO BE SIGNED IN THE PRESENCE OF A FIRST-CLASS MAGISTRATE / DEPUTY

COMMISSIONER / DISTRICT OR SUB-DIVISIONAL MAGISTRATE / TEHSILDAR WHO WILL
ALSO AFFIX HER / HIS SEAL AND SIGNATURE

Round seal of the

Authority’s Signature
authority’s office

Name of the Signatory

Place:

Date: Square seal of the Signatory

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 SCHEDULE (Details of Family Income)

1. Extent of land held and income:

a) Independently as owner:
i. Area
ii. Survey No.
iii. Village
iv. Land revenue assessment
v. Annual income Rs.
Note: Whether the whole or part of the land had been given out to tenants. If yes, give particulars.

b) Jointly as owner:
i. Area
ii. Survey No.
iii. Village
iv. Land revenue assessment
v. Annual income Rs.

c) Independently as a tenant:
i. Area
ii. Survey No.
iii. Village
iv. Land revenue assessment
v. Annual income Rs.

d) Jointly as a tenant:
i. Area
ii. Survey No.
iii. Village
iv. Land revenue assessment
v. Annual income Rs.

2. Property held and Income (House, Shop, Building, House Sites, etc.):
i. House No.
ii. Street/Road
iii. Village/Town/City
iv. Area of the building
v. Rent derived, if any Rs.
vi. House tax paid Rs.
vii. Sanitary cess and other house taxes paid Rs.
viii. Net annual income after deduction of item(vi) and (vii) Rs.

3. Income from shops:

i. Address of shop
ii. Nature of trade
iii. Licence No.
iv. Sales tax, income tax paid Rs.
v. Annual income Rs.

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4. Salary and / or Pension drawn: (Please attach Salary/Pension Certificate)

i. Designation Rs.

ii. Address of Office Rs.

iii. Office/unit in which working
iv. Gross Annual emoluments Rs.
(including all allowances) for the
year ended 31st March 2018
without deduction of income tax

5. Other sources of income in FY: 2017-18:

i. Income from subsidiary industries Rs.

ii. Part-time occupation Rs.

iii. Amount drawn as wages Rs.
iv. Interest/Dividend income Rs.
v. Any other income Rs.

6. Annual income of spouse FY 2017-18 (from any source) Rs.

7. Annual income of applicant from any source FY 2017-18 Rs.

8. Total income of the family in FY 2017-18 (sum of Nos. 1-7) Rs.
9. Savings including Provident Fund Rs.

10. If there is a decrease in the annual income of the parents of the applicant from that shown during the
last year, the reason should be furnished in brief:

Date:

Place:
Signature of the Parent of Applicant

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