APPENDIX-I
[Rule 3(1)]
Return of Assets and Liabilities
on First Appointment or as on the 31st March, 20……..*
(Under Sec 44 of the Lokpal and
Lokayuktas Act, 2013)
1. Name
of the Public servant in full………………………………………………………
(in
block letters)
2. (a)
Present public position held …………………………………………………..
(Designation, name and address …………………………………………………..
of organisation) …………………………………………………..
(b)
Service to which belongs ……………………………………………………
(if applicable)
Declaration:
I hereby declare that the return enclosed
namely, Forms I to IV are complete, true and correct to the best of my
knowledge and belief, in respect of information due to the furnished by me
under the provisions of section 44 of the Lokpal and Lokayuktas Act, 2013.
Date…………………………… Signature………………………...
* In case of first appointment
please indicate date of appointment.
……………………………………………………………………………………
Note 1. This return shall contain
particulars of all assets and liabilities of the public servant either in his/
her own name or in the name of any other person. The return should include
details in respect of assets/ liabilities of spouse and dependent children as
provided in Section 44 (2) of the Lokpal and Lokayuktas Act, 2013.
(Section 44(2): A public servant
shall, within a period of thirty days from the date on which he makes and
subscribes on oath or affirmation to enter upon his office, furnish to the
competent authority the information relating to –
(a) the
assets of which he, his spouse and his dependent children are, jointly or
separately, owners or beneficiaries;
(b) his
liabilities and that of his spouse and his dependent children.)
Note 2: If a public servant is a
member of Hindu Undivided Family with co- parcenary rights in the properties of
the family either as a ‘Karta’ or as a member, he should indicate in the return
in Form No. III the value of his share in such property and where it is not
possible to indicate the exact value of such share, its approximate value.
Suitable explanatory notes may be added wherever necessary.
Note 3: “dependent children” means sons and
daughters who have no separate means of earning and are wholly dependent on the
public servant for their livelihood. (Explanation below Section 44(3) of Lokpal
and Lokayuktas Act, 2013).
APPENDIX-II
[Rule 3 (1)]
FORM No.I
Details of Public
Servant, his/ her spouse and dependent children
Sl. No.
|
Name
|
Public
Position held, if any
|
Whether
return being filed by him/ her, separately
|
|
1
|
Self
|
|||
2
|
Spouse
|
|||
3
|
Dependent-1
|
|||
4
|
Dependent-2
|
|||
5
|
Dependent-3
|
Add more rows, if necessary.
Date…………………………… Signature…………………
FORM
NO.II
Statement
of the movable assets of self, spouse and dependent children:
Details of movable assets of self,
spouse and dependent children.
Sl. No.
|
Description
|
Amount in Rupees
|
||||
Self
|
Spouse
|
Dependent 1
|
Dependent 2
|
Dependent 3
|
||
(i)
|
Cash in hand
|
|||||
(ii)
|
Details of deposit in Bank accounts (FDRs,
Term Deposits and all other types of deposits including saving accounts),
Deposits with financial Institutions, Non- Banking financial Companies and
Cooperative societies and the amount in each such deposit
|
Name of Bank/ Financial Institutions, &
Nature of Deposit
|
||||
(iii)
|
Details of investment in Bonds, debentures/
shares and units in companies/ mutual funds and others
|
Name of company
|
||||
(iv)
|
Details of investment in NSS, Postal Saving,
Insurance Policies and investment in any Financial instruments in Post office
or Insurance Company
|
Nature of investment
|
||||
(v)
|
Detail of deposit in Provident Fund/ New
Pension Scheme
|
Nature of Investment
|
||||
(vi)
|
Personal loans/ advance given to any person
or entity including firm, company, Trust etc. and other receivables from
debtors and the amount (exceeding
(a)two months basic pay, where applicable)
(b) Rupees one lakh in other cases
|
Name of Debtor
|
||||
(vii)
|
Motor Vehicles/ Aircrafts/ Yachts/ Ships
(Details of Make, registration number etc., year of purchase and amount)
|
Nature of vehicle, registration no. &
year of purchases
|
||||
(viii)
|
Jewellery, bullion and valuable thing(s)
(give details of weight)
JEWELLERY
****
Bullion
|
Gold
|
||||
Silver
|
||||||
Precious stones/ precious metals
|
||||||
Gold
|
||||||
Silver
|
||||||
Precious stones/ precious metals
|
||||||
(ix)
|
Any other assets
|
|||||
Date………… Signature………………...
Note 1: Assets in joint name
indicating the extent of joint ownership will also have to be given.
Note 2: In case of deposits/
Investments, the details including Amount, date of deposit, the scheme, Name of
the Bank/ Institution and Branch are to be given
Note 3: Value of Bonds/ Share
Debentures as per current market value in Stock exchange in respect of listed
companies and books values in case of unlisted firms.
Note 4: Details including amount
is to be given separately in respect of each investment.
Note 5: Under (ix) details of
movable assets not covered in (i) to (viii) above valuing individually over two
months basic pay (where applicable), or Rs. 1.00 lakh may be indicated.
FORM
NO.III
Statement of
immovable property on first appointment or as on the 31st March, 20…
(e.g. Lands, House, Shops, other Buildings, etc.)
[Held by Public Servant,
his/ her spouse and dependent children]
Sl. No.
|
Description of property
(Land/ House/ Flat/ Shop/ Industrial etc.)
|
Precise location (name of District,
Division, Taluk and Village in which the property is situated and also its
distinctive number, etc.)
|
Area of land (in case of land and buildings)
|
Nature of land in case of landed property
|
Extent of interest
|
If not in name of public servant, state in
whose name held and his/ her relationship, if any to the public servant
|
Date of acquisition
|
How acquired (Whether by purchase, mortgage,
lease, inheritance, gift or otherwise) and name with details of person/
persons from whom acquired (address and connection of the Government servant,
if any, with the person/ persons concerned) (please see Note 1 below) and
cost of acquisition.
|
Present value of the property (if exact
value not known, approx value may be indicated)
|
Total annual income from the property
|
Remarks
|
1
|
2
|
3
|
4
|
5
|
6
|
7
|
8
|
9
|
10
|
11
|
12
|
Date….....
Note (1) For purpose of Column 9, the term
“lease” would mean a lease of immovable property from year or for any term
exceeding one year or reserving a yearly rent. Where, however, the lease of
immovable property is obtained from a person having official dealings with the
Government servant, such a lease should be shown in this Column irrespective of
the term of the lease, whether it is short term or long term, and the
periodicity of the payment of rent.
FORM NO. IV
Statement of Debts and Other Liabilities on first
appointment or as on 31st March, 20…..
Sl. No.
|
Debtor
(Self/ Spouse or dependent children)
|
Amount
|
Name and
address of Creditor
|
Date of
incurring Liability
|
Details of
Transaction
|
Remarks
|
1
|
2
|
3
|
4
|
5
|
6
|
7
|
Date:……………………… Signature……………….
Note 1: Individual items of loans not exceeding two months
basic pay (where applicable) and Rs. 1.00 lakh in other cases need not be
included.
Note 2: The statement should also include various loans and
advances (exceeding the value in Note 1) available from the employer like
advance for purchase of conveyance, house building advance etc. (other than advances of pay and travelling
allowance), advance from the GP Fund and loans on Life Insurance Policies and
fixed deposits.
[F.
No. 407/12/2014-AVD-IV (B)]
