GOVERNMENT OF PUNJAB
REGULATION WING
SERVICES & GENERAL ADMINISTRATION
DEPARTMENT
DECLARATION OF INCOME AND ASSETS
Financial Year Ending on 30th June _________
1. Name
NIC. No.
NTN. No.
2. Basic Pay
Occupation Group/
Scale
Service/Department
Present Position Held
3. Present
Residential
Address
Phone (R) Mobile
4. Income Salary Rental Agri
(During the (Rs) Income Rs. Income Rs.
Financial Year)
Other Sources (dividend, profit, prize money, gift, loan etc.) Total
Rs. Rs.
5. Expenses Utilities (Electricity Total Household
(Approx) Gas, Telephone etc.) Expenses
Rs. Rs.
6. Private Foreign Traveling Country/Countries Period of stay Aprox. Expenses
(Self, Spouse & Children) visited from____ to _____ Rs.
During F.Y ___________ _________________ ________________ _______________
_________________ ________________ _______________
7. Children’s Education Name (s) of children Education institutions
Attended during F.Y. ______________
8. Club Membership Name of Club (s) Membership No.
ASSETS & LIABILITIES
9. Immovable Assets (Agri & Non-Agri lands, House properties, Commercial & Industrial
properties, open plots of all types)
Identification & nature of Asset(s) Mode of acquisition/year Cost of acquisition
a)
b)
c)
d)
e)
f)
g)
h)
i)
j)
k)
l)
m)
10. Moveable Assets (Cash in hand, Motor vehicles, Jewelry, Household items, Equipment, Business
capital etc.)
Identification & nature of Asset(s) Mode of acquisition/year Cost of acquisition
a)
b)
c)
d)
e)
f)
g)
h)
i)
j)
k)
l)
m)
Total
11. Assets held as Attorney
Identification & nature of Asset(s) Nature of Power of Name & Address of
Attorney the Legal Owner
(Revocable/Irrevocable)
a)
b)
12. Assets disposed off during the year
Identification & nature of Asset(s) Date of disposal Amount received as
sale proceed (Rs.)
a)
b)
c)
13. Investments (Bounds, Shares, Certificates, deposits/Advances, loans granted etc.)
Detail of bonds held Investment
a)
b)
c)
d)
e)
f)
Total
14. Bank Accounts (Current, Saving, Deposit A/c & F.C. A/cs)
A/c No. & Bank Branch Year of Opening Main source of deposits Balance on______(Rs.)
a)
b)
c)
d)
Total
15. Total Assets ( ) Rs.--------------------
16. Liabilities (Departmental/ Bank Loan, Over drafts, Mortgages secured, private loans etc)
Outstanding liabilities (A) Liabilities paid off during the year (B)
a)
b)
c)
d)
(15-16 (A)) Net worth Rs.____________
As on 30.6.__________
Net worth declared previously Rs.___________
As on 30.6.___________
Signature______________________________
Name
Designation
Name of the Organization/Deptt.
Place ___________
Date______________________________
INSTRUCTION
1. If the space provided in the form is found inadequate or some
explanation is required, a separate page may be attached/ annexed.
2. All assets should be valued at cost and in the cases of assets acquired
through gift name, address of the donor and donees relationship with
him is to be declared.
3. Income declared at serial No. 4 must include income earned by the
spouse & children as well.
4. Information requested must be complete. No column should be left
blank. Columns which are not applicable should be crossed.
5. All assets owned by the officer & his family members (Family as
defined in Rule 3 (1)(c) of conduct Rules 1966) should be declared.
Assets acquired by major children dependents & others where funds
have been provided by the officer are also to be declared.
6. Assets owned by partly or acquire on “Hire purchase Agreement” or
installment should also be declared.
7. If any exact figure cannot be inserted an estimated/ approx figure may
be given.
8. Sale proceeds of assets disposed off during the relevant financial year
must be declared under the head “other sources” (Serial No. 4).
9. If there is no change in Assets over the previous year (for which the
declaration has been filed) relevant columns (Serial No. 9, 10 & 11)
may be marked “As before”.
10. At Serial No. 11 assets held by others as attorney on behalf of
declarant, his spouse or dependent children are also to be declared.
11. Expenses against utilities (Serial No. 5) should include bills paid
against all meters (Gas & Electricity installed on the residence) and
telephone connections (including Mobile) in use of the officer, spouse
& dependent children.
12. Notwithstanding the applicability of other law for the time being in-
force this declaration is being filed under Conduct Rule 1966 and any
breach thereof (including concealment of assets or giving wrong
information) is punishable under PEEDA Act 2006.
