Government of Kerala

Finance Department
Application for Education Loan Repayment Support Scheme

Student Registration Number. : 5022310107 Date of Submission : 2017-09-22

Personal Details

Type Of Student : Normal Student

Student Name : AMRUTHA K
Gender : F
Date of Birth : 03/03/1992
Secondary Board Exam Roll Number(10th Board : 502231
Examination Roll No.) *
Year of Passing 10thclass * : 2007
Board in which 10thclass Passed * : Kerala Board
House Number : 182
House Name : keloth house
Street : chembra
Area/Locality : (R)ural
Post office : mattanode
Taluk : koyilandy
Pin Code : 673527
District : Kozhikode
Mobile Number : 8792163411
Email Address : uk.uk21@gmail.com
Aadhaar Number : 836029609821
IT PAN Card Number : ELHPK7992H
Category : GEN
Name of Father/Mother/Guardian/Spouse : bhaskaran k a nair

Course Details

Seat Type : management

Course Type : UNDER GRADUATE
Name of Professional Course : BSc Nursing
State of Institution/College/University : Karnataka
District of Institution/College/University : Bangalore
Name of Institution/College/University : Presidency College of Nursing
Affiliation/Accreditation of the Institution/College/ : karnataka nursing council
University
Course Completed : Yes
Period of Course : 2009-2013
Date of Commencement of Course : 01/09/2009
Date of Course Completion : 27/09/2013
Due Date for Commencement of Repayment : 27/09/2014

IT Services:National Informatics Center(NIC),Kerala Page 1 Date:22/09/17

Loan Details

Bank Type from which loan availed : STATE BANK OF INDIA

Bank State : Kerala
Bank District : Kozhikode
Branch Name : PERAMBRA ADB
IFSC Code : SBIN0003995
Account Number : 30926770497
Date of Loan Sanctioned : 07/10/2009
Amount of Loan Sanctioned (in Rupees) : 250000
Amount of Loan Disbursed (in Rupees) : 250000
Amount of Loan Outstanding (in Rupees) : 397000
Amount Repaid : 10000
Area : (R)ural

Income and Other Details

Is Student Employed : No
Family Annual Income (in Rupees) : 24000
Income Certificate Number : 27393210
Income certificate Date : 30/08/2017
Relief availed/claimed under other scheme, if any : No
other than Central/State Interest Subsidy Scheme
Is NPA : Yes
loan Settlement Option : Regularization of loan account

IT Services:National Informatics Center(NIC),Kerala Page 2 Date:22/09/17

 Declaration
I/We declare that I/We am/are eligible for repayment support under the said repayment support scheme and
hereby request the Bank to process my/our application to extend the benefit under the said Scheme to me/us. I/We
declare that the information supplied above, is correct and that this application will form the basis of claiming repayment
support on my/our Education loan from the State Government under the said scheme. I/We shall inform the Bank
immediately in case of any change in the above details and information given in this application form. I/We agree to
provide any further information and /or documents required and demanded by the bank/Government. I/We hereby offer
my/our consent for disclosure of information relating to me/us & any of the facilities proposed by me/us to regulators i/e.
Nodal agency appointed under the scheme by State Government.

I/we declare that my share of contribution will be remitted on demand by the bank.

Signature of Co-Applicant Signature of Applicant

(In the case of expired borrower student)

Date:

Place:

IT Services:National Informatics Center(NIC),Kerala Page 3 Date:22/09/17

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