Say Assistance Form

Form of particulars to be filled up by a person claiming assistance from SAY Education Assistance Fund

Affix passport size photo within the box

To, The Screening Committee Someone Always Yours. Dear Sir,

I request that I may be provided financial assistance for availing Studies from Someone Always Yours Education Assistance Fund. Below given are my particulars: 1

2

3

Details of the applicant (i)

Name

:

(ii)

Date of Birth

:

(iii)

Address

:

(iv)

Name of the Institution

:

Details of Father (i)

Name

:

(ii)

Occupation

:

(iii)

Address

:

(iv)

Monthly Income (Attach Proof)

:

(v) No. of dependants Details of Mother (i)

Name

:

(ii)

Occupation

:

(iii)

Address Monthly Income (with documentary proof) No. of dependants

:

(iv) (v)

:

4

Total monthly /annual fees of the Applicant.

5

Source from which the applicant is presently meeting his/her fees :

6

Marks secured in percentage / grade of the last given Examination (term-wise) Percentage Examination Term

:

(i) (ii) (iii) 7

Whether Physically Challenged (Enclose attested copy of medical certificate) :

8

Particulars of other family members of the applicant. Sl. No.

(i) (ii)

Name

Age

Relation

Occupation

Annual Income

(iii) 9

Particulars of School where the applicant had studied Sl. No.

Name of School

Class Passed

% Obtained

Remarks

(i) (ii) (iii) (iv) 10

Whether any assistance received / likely to be received from any other source, and if so, provide details.

11

The extent of financial help sought from the Someone Always Yours Education Assistance Fund

I hereby declare that the particulars given above are true and complete to the best of my knowledge and belief and I have not concealed any information there from. I am aware that in the event of any information, if found to be false, distorted or twisted later, I will be disqualified from the receipt of any assistance from S.A.Y. would be bound to refund the amount if received. Date : Yours faithfully

(Parent’s Name and Signature)

(Candidate’s Name and Signature)

“I have gone through the particulars in the application form which has been filled in completely and the particulars stated therein are prima facie correct. In my opinion, it is a deserving case and financial assistance from S.A.Y. may be sanctioned as per the guidelines”

Suyash Tulsyan

Mahesh Agarwal

(Screening Team Member)

(Screening Team Member)

Md. Zoheb Khan

Ravi Agarwal

(Screening Team Member)

(Screening Team Member)

Date :

Stamp