DECLARATION OF INCOME AND ASSETS
Financial year Ending on 30th June _____________
Name
NIC No.
N.T. No. - - - - - - - - - - - - - - -
Pasic pay Scale
Occupation Group
Service/Department
Present position held
Present Residential Address
Phone (R) Mobile
Income Salary Rental income Agrl income
(During the Rs. Rs. Rs.
Financial year)
Other sources (dividend profit, prize, money, gift, loan etc) Total
Rs. Rs.
Expenses Utilities (Electricity) Total Household
(Approx) Year-2018 Gas Telephone etc.) Expenses
Rs Rs.
Private Foreign Traveling Country/Countries
Period of stay Approx expenses
(Self, Spouse & Children visited from _____to ______ Rs.
During F.Y. _________ ______________ _______________ _____________
Children’s Education Name(s) of children Educational institutions
(Inland & abroad) attended during F.Y___________
______________ _______________________________________
______________ _______________________________________
______________ _______________________________________
______________ _______________________________________
Club Membership Name of Club (s) Membership No.
________NIL_________ ________NIL_________ ___________NIL____________________
ASSETS & LIABILITIES
Immoveable Assets (Agrl & Non-Agrl lands, House properties, Commercial & Industrial
Properties, Open plots of all types)
Identification & nature of Assets (s) Mode of acquisition/year Cost of acquisition
a)
b)
c)
d)
e)
f)
g)
h)
i)
j)
k)
l)
m)
Moveable Assets (Cash in hand, Motor vehicles, jewelery, Household items Equipment,
Business capital etc.)
Identification & nature of Assets (s) Mode of acquisition/year Cost of acquisition
a)
b)
c)
d)
e)
f)
g)
h)
i)
j)
k)
l)
m)
Assets held as attorney
Identification & nature of Assets (s) Nature of power of attorney Name & Address of
(Revocable/irrevocable) the legal owner
a)
b)
c)
Assets disposed off during the year
Identification & nature of Assets (s) Date of disposal Amount received as sale proceed
(Rs.)
a)
b)
c)
d)
Investments (Bonds, shares, Certificates, deposits/advances, Loans granted etc.)
Details of Bonds held Investments
Bond No (s) Denomination Rs.
a)
b)
c)
Bank Accounts (Current, Saving, Deposit A/c & F.C A/cs)
A/c No. & Bank Branch Year of Main source of deposits Balance on 30.6.
Opening (Rs)
a)
b)
c)
d)
e)
f)
g/
Total Assets (9 – 14 ) Rs. ___________ Millions
Liabilities (Departmental/Bank loans, over drafts, Mortgages secured, private loans etc.)
Outstanding liabilities (A) Liabilities paid off during the year (B)
a) Rs. Rs.
b) Rs. Rs.
c) Rs. Rs.
d) Rs. Rs.
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________________________
INSTRUCTIONS
1. If the space provided in the form is 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
3. Income declared at Serial 4 must include income earned by the
4. Information requested must be complete. No. column should be left blank
5. All assets owned by the officer and his family members (Family as defined in Rule 3(1)(c) of Conduct Rules, 1978
should be declared. Assets acquired by major children dependents & others where funds have been provide by the
officer are also to be declared.
6. Assets owned partly or acquired on “Hired purchase Agreements” 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 heard “other
sources” (Serial 4).
9. If there is no change in Assets over the previous year (for which the declaration had been filed) relevant columns (Serial
9, 10 & 11) may be marked “As before”.
10. At Serial 11 assets held be others as attorney on behalf of declarant, his spouse or dependent children are also to be
declared.
11. Expenses against utilities (Serial 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 & dependents children.
12. Notwithstanding the applicability of any other law for the time being in-force, this declaration is being filed under
Conduct Rule 1978 and any breach thereof (including concealment of assets or given wrong information) is punishable
under RSO 2000.
