SNBS1 (PDF)

Account Code No._________________

Indian Institute Of Management, Ahmedabad
SPECIAL NEED-BASED SCHOLARSHIP FORM (SNBSF)
(To be filled in and signed by the applicant, and counter signed by Parents/Guardians. Please keep a photocopy of the duly
filled form and attachments for your reference)
____________________________________________________________________________________________________
STUDENTS, WHOSE ANNUAL FAMILY INCOME FOR THE FINANCIAL YEAR 2016-17 IS BELOW RS. 15 LAKHS ARE ELIGIBLE TO
APPLY FOR THIS SCHOLARSHIP. ELIGIBLE STUDENTS MAY SUBMIT THEIR APPLICATIONS ALONG WITH RELEVANT DOCUMENTS
ON OR BEFORE JULY 25, 2016 TO THE ADMISSIONS OFFICER, IIM, VASTRAPUR, AHMEDABAD 380 015. APPLICATION
SUBMITTED AFTER DEADLINE WILL NOT BE CONSIDERED. THE INSTITUTE HAS EVERY RIGHT TO ACCEPT OR REJECT THE SNBS
APPLICATION FORM SUBMITTED BY THE STUDENT.
___________________________________________________________________________________________________
Personal Information
1.

Name of the student
(In block letters)





Last











First







PGP – I / PGP-FABM – I (Batch 2016-18)







Roll No._________________

2.

Phone No.: Land Line (________) _____________ Mobile __________________________
STD code

3.

Present Address







Middle











































Permanent Address

































5.

D.O.B







6.

Marital Status:



Single/Married







4.



1

(a) If yes, what was the date of your marriage ?
(b) If yes, please provide the following details:
What was the income of your spouse during 2015-16 in case
you were married for the whole or part of 2015-16?

`

(Note: Income here means income from all sources prior to any deductions allowed by Income Tax Act)
8.

Were you working? If yes, since how long?
Also indicate the salary being drawn and the savings from your income
Salary: `

9.









Savings: `





Indicate the amount of educational loan you intend to take for your studies (for 2 years) at IIMA `____________
st

Amount availed so far (for 1 year) ` _______________



Enclose attested copy of marriage certificate

1

1




Name of the Bank ___________________________________________ Branch______________________________
Loan Account No. _________________________ MICR Code ________________________IFS Code _____________
Rate of Interest per annum________ Terms related to Interest payment ___________________________________
Terms related to principal repayment _______________________________________________________________
Address of the bank______________________________________________________________________________
2

Parental Information :
1)

Names of your





Father/ Guardian : ________________________________________
Mother/Guardian : ________________________________________

2)

Age of your






Father/ Guardian : ________________________________________
Mother/Guardian : ________________________________________

3)

Educational Qualifications




Father/ Guardian : ________________________________________
Mother/Guardian : ________________________________________

4)

Occupations of your:




Father/ Guardian : ________________________________________
Mother/Guardian : ________________________________________

5)

If any of the parents/guardians is in service, give:
i)

ii)

Designation of






Father/Guardian

: ________________________________________







Mother/Guardian : ________________________________________

Address of employer : _____________________________________________________________________

___________________________________________________________________________________________
iii)

No. of years in service : ___________________________

(Note: If retired, give details of previous job in items i), ii) and iii) above






iv)

Gross annual salary during 2015-16
Father/Guardian

`____________________

Mother/Guardian `____________________
v)

3

Income from other sources during 2015-16
Father/Guardian

`____________________

Mother/Guardian `____________________



Parental information will include information about both parents even if they are separated or divorced.

2

3

Income from other sources includes among other things, interest/dividend income, rentals/property-related income, income from agriculture, and
pension.

2


vi)

Total income from all sources during 2015-16
Father/Guardian

`____________________

Mother/Guardian `____________________
6)

Total `_________________

If any/both of the parents/guardians is/are self-employed, give:

A. Father/Guardian
i)

Nature of business: Sole proprietor/Partner : __________________________________

ii)

Indicate the name of the Company : ____________________________________________________

iii)

Annual Income:

YEAR------> 2015-16 `___________________

B. Mother/Guardian
i)

Nature of business: Sole proprietor/Partner : __________________________________

ii)

Indicate the name of the Company : ____________________________________________________

iii)

Annual Income:

YEAR------> 2015-16 `___________________


7)

TOTAL ANNUAL PARENTAL INCOME FOR THE YEAR 2015-16:

8)

Parents’ Principal Assets and Liabilities

i)

Life Insurance Policy


Name of the insured

Year in which policy Face Value of the
taken
policy (`)

a) Father/Guardian





b) Mother/Guardian



c) Others


ii)

(5vi + 6Aiii & Biii) `___________________

Annual Premium
(`)

Loan
outstanding, if
any (`)

Present value after
deducting loan
outstanding (`)























Immovable Properties


House property (Indicate location and address)

Present sale value (a) Unpaid mortgage (b)
(`)
(`)

Difference (a-b)
(`)
















Total


Agricultural land, No. of acres (Indicate place, location, Present sale value of
wet/dry, etc.)
land (a) (`)

Unpaid mortgage (b)
(`)

Difference (a-b)
(`)
















Total



3


Other real estate

Present sale value of the Unpaid mortgage (b)
(`)
property (a) (`)

Difference (a-b) (`)
















Total


iii)

Movable Properties

i.

Capital value of the share holdings (if doing business)

`

ii.

Market value of other investment - shares, bonds, vehicles, etc.

`

iii.

Savings (current account/fixed and bank deposits)

`

iv.

Provident Fund

`
Total `



9)

Sl.
No.


List all the members of your family including the earning members with their monthly incomes and all dependents on the
incomes.
Name

Age





Relationship with
the student





Income Tax Account No.
(PAN No.) and Area Code



















































b)









c)





d)



e)
f)

a)

Monthly
Income



Occupation



10) Tick mark and enclose documents produced as proof:
a)

If employed, Form-16 from employer duly signed and stamped with Income Tax Return for the Financial Year 2015-16
(Assessment Year 2016-17). If the income as per Form-16 and ITR does not match, you have to enclose the Statement of
Computation of Income duly attested by a Chartered Accountant.

b) If retired, pension certificate from the Bank Manager, certifying the annual pension amount for the period for 2015-16 to
be produced along with Income Tax Return for 2015-16 (Assessment Year 2016-17). If you have income other than
pension, you need to produce an Income certificate duly attested by District Magistrate or Tehsildar specifically
mentioning the year or Income Tax Return for the Financial Year 2015-16 (Assessment Year 2016-17).
c)

If employed in business, certified copy of Income Tax Return for the Financial Year 2015-16 (Assessment Year 2016-17)
along with Computation of Income statement (with P&L Account, Capital Account and Balance Sheet) duly certified by a
Chartered Accountant.

d) For those who are not required to file Income Tax Returns, Income Certificate from the competent authority or an
affidavit duly attested by District Magistrate or Tehsildar for the period 2015-16 is to be produced.
e) Declaration/Affidavit for the non-earning members in the family for the period 2015-16 is to be produced.
f)

A copy of the loan sanction letter duly attested by the branch manager of the branch from where the loan is availed.

4


g)

A notarized Affidavit on a non-judicial stamp paper of Rs.50/- in the attached format is to be produced.

I certify that the particulars given by me in this form represent our financial position and are true to the best of my knowledge and
belief. I have no objections in case Indian Institute of Management, Ahmedabad were to investigate the veracity of details supplied
by me in this form and such an investigation, which is the basis of the Special Need-based Scholarship being availed by me, would
not amount to infringement of my privacy.
I agree to submit any clarifications/additional documents sought by the Institute’s auditors on subsequent scrutiny of my
scholarship application form and pay for the difference in fees if the annual income is found to be more than the declared amount.
I also agree to adhere to the existing rules and regulations of the financial aid of the Institute.
The affidavit in support of my application for Special Need based scholarship is also submitted with the Institute. In case the
documents and details submitted by me found to be incorrect, misleading or not according to my SNBS form, I consent and
unequivocally authorize the Institute to expel me from Institute during the Programme, revoke the diploma/degree certificate
issued by the Institute. Even after successful completion of the Programme and awarded the diploma/degree for the same, the
Institute will have right to cancel my diploma/degree certificate if details submitted by me found to be incorrect, misleading or not
according to my SNBS form. In that case, I will have no right to oppose against any action of the Indian Institute of Management,
Ahmedabad. Indian Institute of Management, Ahmedabad will be at liberty to recover the said amount from me without giving any
further opportunity. The Indian Institute of Management, Ahmedabad will also be at liberty to initiate appropriate legal action in
accordance with Law.



Signed by Candidate











Counter signed by Parents/Guardians

Date:











Date:






Please mention below the list of enclosures attached with this form:




5


On Rs. 50/- stamp paper or On Rs. 50/- franking document.

A F F I D A V I T


I, ……………………………………………………., religion…………………….. residing
at…………………………………………………………………………......................................................
..................................(permanent address) do state on solemn affirmation that:
I have applied for the Special Need Based Scholarship from the Indian
Institute of Management, Ahmedabad.
In this regard I would like to state that, I have gone through the rules
and regulations of the Institute and I declare that I am fit person to get the
benefits mentioned in the said Special need based scholarship at the Institute.
I also declare that I have submitted details in SNBS Form (Special Need Based
Scholarship Form) in respect of my parental income, details of movable &
immovable property, assets, ownership & liability with all other necessary
information.
I also agree that, Indian Institute of Management, Ahmedabad or any
agency or third party agency or any person authorized by Indian Institute of
Management, Ahmedabad will have right to investigate & verify the
authenticity of the documents and details submitted by me for the same at
any point of time during and even after the completion of my PGP/PGPFABM.
I say that in case, the documents and details submitted by me found to
be incorrect, misleading or not according to my SNBS Form, the Institute will



have right to expel me from Institute during the Programme or revoke the
Diploma/Degree certificate issued by the Institute. Even after successful
completion of the Programme and awarded the dipoma/degree for the same,
the Institute will have right to cancel the Diploma/Degree certificate if details
submitted by me found to be incorrect, misleading or not according to my
SNBS Form. In that case, I will have no right to oppose against any action of
the Indian Institute of Management, Ahmedabad. The Indian Institute of
Management, Ahmedabad will be at liberty to recover the said amount with
due interest from me without giving any further opportunity.
I have read the form for Special Need based scholarship and related
literature, I agree to be abide by the same & found fit for the same. I also
declare that the information and documents submitted by me are true to best
of my knowledge and belief and also agree to submit originals of the same
whenever sought by the Institute. This affidavit is filed by me with the
Institute in support of getting benefits under Special need based scholarship.
I understand that making false affidavit is an offence.

Place:



Date: / /







____________________







Deponent



(Name of Applicant)