RETURN OF ASSETS AND LIABILITIES AS ON 31-12-20__

1. Name of the Government Servant in full (In block letters):-

2. Service to which he/she belongs:-

3. Total length of service as on date :-

(i) In Non GAZETTED rank:-

ii) In GAZETTED rank:-

4. Present post and place of posting:-

5. Total annual income from all sources during the Calendar year immediately proceeding the 1st day of January, 20__

DECLARATION:

I hereby declare that the particulars from FORM I to V are complete, true and correct as on 31-03-20__, to the best of my
knowledge and belief, in respect of information due to be furnished by me under the provisions of Sub-Rule (i) of Rule 18 of
the Central Civil Service (Conduct) Rule, 1964.

Date:- Signature:

Note: 1.This return shall contain particulars of all assets and liabilities of the Government servant either in his own name or in the
name of any other person.
2. If a Government servant is a member of Hindu undivided Family with coparcener rights in the properties of the family
either as a “Karta” or as a member, he should indicate in the return in item No. I the value of such share in such property
and where it is not possible to indicate the exact value of such share its appropriate value suitable explanatory notes may
be added wherever necessary.
 FORM NO: I
STATEMENT OF THE IMMOVABLE PROPERTY AS ON 31-12-20__
(i.e. LANDS, HOUSE, SHOPS, and OTHER BUILDING ETC.)

Sr. Description Precise location Area of Nature of land (in Extent of If not own Date of How acquired (whether by Value of Particulars Total
No property (Name of District, land (in case of landed interest name state in Acquisition purchase, mortgage, lease property of annual
Division, Tehsil case of land property) whose name inheritance gift or otherwise) (See note 2 sanctions income
and Village in & Building) held & his/her & name with details of below) of from the
which the property relationship if person(s) from whom prescribed property
is situated and also any, with the acquired (address and authority,
its distinctive Govt. Servant connection of the Govt. if any
number etc. Servant if any, with the
person/persons concerned
please see note 1 below)
1 2 3 4 5 6 7 8 9 10 11 12

Date:- Signature: ______________________

Name :
Note:-1. For purpose of column 9 of the term (Lease would on a lease of immovable property from year to 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 Govt. servant, such a lease should be shown in this in respect of the term of the lease whether it is short term or long term and periodically of the payment of the
rent.
2. In Col. No. 10 should be shown (a) where the property has been acquired by purchase, mortgage or lease, the price or premium paid for such acquisition (b) where it has been acquired by lease the total annual rent there of
also.
 Form No. -II

STATEMENT OF LIQUID ASSESTS ON 31-12-20__

i.) Cash and Bank Balance exceeding 3 months emoluments. ii.) Deposits, loans advances and investments. (Such as shares,
securities and debentures etc.)

Sr. Description Name and addresses Amount If not in own name and address of Annual Income Remarks
No. of company, Bank persons in whose name held and derived
etc. his/her relationship with the Govt.
Servant
1 2 3 4 5 6 7

Date:- Signature: ______________________

Name :
Note:-1. In column 7, particulars regarding sanctions obtained or report made in respect of the various transactions may be given.

2. The term “emoluments’ means the pay and allowances received by the Govt. servant.
 FORM NO – III

STATEMENT OF MOVABLE PROPERTY AS ON 31-12-20__

Sr. Description of Price of value at the time of acquisition If not in own name, name How acquired with Remarks
No. item and /or the total payment made upto and address of the persons approximate date of
the date of return, as the case may be, in whose name and his/her acquisition
in the case of articles purchased on hire relationship with Govt.
a purchase of installment basis. employee
1 2 3 4 5 6

Date:- Signature: ________________

Name :

Note:-
1. In this form/information may be given regarding items like (a) jewelry owned by him (total value) (b) Silver and other precious metals and precious stones owned by him not forming part of jewelry (total value), (c) (i)
Motor Cars (ii) Scooters/Motor Cycles (iii) Refrigerators/Air-Conditions (iv) Radios/Radiograms/Television sets and any other articles, the value of which individually exceeds Rs. 1000/- (d) Value of items of movable
property individually worth less than Rs. 1000/- other than articles of daily use such as clothes, utencils, books, crockery etc. added together as lump sum.
2. In column 5 may be indicated whether the property was acquired by purchase, inheritance gift or otherwise.
3. In column 6 particulars regarding sanctions obtained or report made in respect of various transactions may be given.
 FORM NO – IV
STATEMENT OF PROVIDENT FUND AND LIFE INSURANCE POLICY (As on 31st December 20__)

Sr. Insurance Name & Sum Amount PROVIDENT FUND

No. policy No. insurance Insured/ of Annual Type of Closing Contribution Total Remarks (If there is
and date Company date of premium provident balance as made dispute regarding
of policy maturity funds/ last reported subsequently closing balance the
GPF/CPF by the Audit figure according to the
Account No. /A. O along Govt. employee should
with date of be mentioned in this
such balance column
1 2 3 4 5 6 7 8 9 10

Date: Signature:__________________________
Name :
 FORM NO – V
STATEMENT OF DEBTS AND OTHER LIABILITIES (As on 31-12-20__)

Sr. Amount Name and address of creditor Date of incurring liability Detail of transaction Remarks
No.
1 2 3 4 5 6

Date:- Signature: ______________________

Name :
Note:-
1. Individual items of loans not exceeding three months emoluments of Rs. 1000/- whichever is less need be included.
2. In column 6, information regarding permission, if any, obtained from or report made to the competent authority may also be given.
3. The term “emoluments” means pay and allowances received by the Govt. employee.
4. The statement should also include various loans and advances available to Govt. employees like advance for purchase of conveyances, house-building advance etc. (other than advances of pay and traveling allowance) advances
from the G. P. Fund and loans on Life Insurance policies and fixed deposit.