10 THE GAZETTE OF INDIA: EXTRAORDINARY [PART II SEC. 3(i)] APPENDIX-I [Rule 3(1)] Return of Assets Liabilities on First Appointment or as on 31 st March, 20 * (Under Sec 44 of Lokpal Lokayuktas Act, 2013.) 1. Name of Public Servant in full (in block letters) 2. (a) Present public position held (Designation, name address of organization) (b) Service to which belongs (if applicable) Declaration: I hereby declare that return enclosed namely, Forms I to IV are complete, true correct to best of my knowledge belief, in respect of information due to be furnished by me under provisions of section 44 of Lokpal Lokayuktas Act, 2013. * In case of first appointment please indicate date of appointment. Note 1. This return shall contain particulars of all assets liabilities of public servant eir in his/her own name or in name of any or person. The return should include details in respect of assets/liabilities of spouse dependent children as provided in Section 44 (2) of Lokpal Lokayuktas Act, 2013. (Section 44 (2):A public servant shall, within a period of thirty days from date on which he makes subscribes an oath or affirmation to enter upon his office, furnish to competent authority information relating to (a) assets of which he, his spouse his dependent children are, jointly or severally, owners or beneficiaries; (b) his liabilities that of his spouse his dependent children.) Note 2. If a public servant is a member of Hindu Undivided Family with co-parcenary rights in properties of family eir as a Karta or as a member, he should indicate in return in Form III value of his share in such property where it is not possible to indicate exact value of such share, its approximate value. Suitable explanatory notes may be added wherever necessary. Note 3. dependent children means sons daughters who have no separate means of earning are wholly dependent on public servant for ir livelihood. (Explantion below section 44(3) of Lokpal Lokayuktas Act,2013).[]
(iii) Details of investment in Bonds, debentures/ Name of company [भ ग II खड 3(i)] भ रत क र जप : अस ध रण 11 1 Self 2 Spouse 3 Dependent-1 4 Dependent-2 5 Dependent-3 6 Dependent-4 7 Dependent-5 8 Dependent-6 *Add more rows, if necessary. FORM NO. I Details of Public Servant, his / her spouse dependent children APPENDIX-II [Rule 3(1)] Name Public Position held, if any Wher return being filed by him/her, separately FORM II Statement of movable property on first appointment or as on 31 st march, 20 Details of movable assets of self, spouse dependent children: Description Amount in Rupees (i) (ii) Cash in h Details of deposit in Bank accounts (FDRs, Term Deposits all or types of deposits including saving accounts), Deposits with financial Institutions, Non-Banking financial Companies Cooperative societies amount in each such deposit Name of Bank/ Financial Institutions, &nature of Deposit Self Spouse Dependent 1 Dependent 2 Dependent 3
12 THE GAZETTE OF INDIA: EXTRAORDINARY [PART II SEC. 3(i)] (iv) Details of investment in NSS, Postal Saving, Insurance policies investment in any Financial instruments in post office or Insurance Company investment (v) (vi) (vii) Detail of deposit in Provident Fund/ New Pension Scheme Personal loans/advance given to any person or entity including firm, company, Trust etc, or receivables from debtors amount (exceeding (a) two months basic pay where application, (b) Rupees one lakh in or cases) Motor Vehicles/Aircrafts/Yachts/ Ships (Details of Make, registration number etc., year of purchase amount) Investment vehicle registration no. & year of purchase (viii) (ix) Jewellery, bullion valuable thing(s) (give details of weight) JEWLLERY Bullion *** Any or assets Gold Silver Stones metals Gold Silver Stones metals
[भ ग II खड 3(i)] भ रत क र जप : अस ध रण 13 Description of property (L/Hous e/flat/shop/ Industrial etc.) FORM NO.III Statement of immovable property on first appointment or as on 31 st March, 20 (e.g. Ls, House, Shops, Or Buildings, etc.) Precise Locatio n(name of District, Divisio n Taluk Village in which propert y is situated also its distincti ve number, etc.) [Held by Public Servant, his/her spouse dependent children] Area of Nature Extent of Date of L of interest acquisit (in case l in ion of l case of led building proper s) ty If not in Name of public servant, state in whose name held held his/her relation ship, if any to public servant How acquired (wher by purchase, mortgage, lease, inheritance, gift or orwise) name with details of person/persons from whom acquired (address connection of Government servant. If any, with person/persons concerned) (Please see Note 1 below) cost of acquisition Present value of propert y (If exact value not known approx, value may be indicate d Total amou nt inco me from prope rty 1 2 3 4 5 6 7 8 9 10 11 12 Remar ks Note (1): For purpose of Colum no. 9, term lease would mean a lease of immovable property from year to year or for any term exceeding one year or reserving a yearly rent. Where, however, lease of immovable property is obtained from a person having official dealings with Government servant, such a lease should be shown in this Column irrespective of term of lease, wher it is short term or long term, periodicity of payment of rent.
14 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II SEC. 3(i)] FORM IV Statement of Debts Or Liabilities on appointment or as on 31 st March, 20 Debtor (Self Spouse or dependent children) Amount Name Address of Creditor Date of incurring Liability Details of Transaction Remarks 1 2 3 4 5 6 7 Note 1: Individual items of loans not exceeding two months basic pay (where applicable) Rs.1.00 lakh in or cases need not be included. Note 2: The statement should include also include various loans advances (exceeding value in Note 1) available from employer like advance for purchase of conveyance, house building advance, etc. (or than advances of pay traveling allowance from GP Fund loans on Life Insurance Policies fixed deposits. [F. 407/12/2014-AVD-IV(B)] P.K. DAS, Jt. Secy.