FORM NO.

STATEMENT OF IMMOVABLE PROPERTY HELD BY

GOVERNMENT SERVANTS

(eg. Lands,House,Shops,Other Buildings etc)

1 Serial No.
2 Description of Property

3 Precise location (Name of

District, Division,Taluk and
Village in which property is
situated and also its
distinctive number, etc
4 Area of land ( case of land
and buildings)
5 Nature of land ( in case of
landed property)
6 Extent of interest
7 If not in own name, state in
whose name held and
his/her relationship, if any,
to the Government servant
8 Date of acquistion
9 How acquired ( whether by
purchase, mortgage, lease ,
inheritance, gift or
otherwise) and name with
details of persons / person
 from whom acquired,
address and connection of
the Government servant, if
any, with the person /
persons concerned ( please
see Note 1 below)
10 Value of the property ( see
Note 2 below)
11 Source of Income
12 Details of payments
13 Particulars of sanction of
prescribed authority if any
14 Total annual income from
the property
15 Remarks

Date : Signature
 FORM NO. III
STATEMENT OF MOVABLE PROPERTY HELD BY
GOVERNMENT SERVANTS
(1) Cash and bank balances exceeding three months emoluments.
(2) Deposits, loans advanced and investments
(Such as shares,securities,debenture etc.)

1 Serial No.
2 Description of Property
 3 Price of value at the time
of acquistion and / or the
total payments made upto
the date of return , as the
case may be, in the case of
articles purchased on hire-
purchase or instalment
basis
4 If not, in own name, name
and address of the persons
in whose name and his /
her relationship with the
Government servant.
5 Sources if Income

6 Details of payments

7 How acquired with

approximate date of
acquisition
8 Remarks

Date : Signature
 FORM No.IV

STATEMENT OF PROVIDENT FUND AND LIFE INSURANCE

POLICY HELD BY GOVERNMENT SERVANTS

1 Serial No.
2 Policy Number and date of
policy
3 Name of Insurance
company
4 Sum insured / date of
maturity
5 Amount of annual
premium
6 Sources of Income
7 Details of payments
8 Type of Provident Fund /
GPF / Acount No.
9 Closing balance as last
reported by the Audit /
Acounts Officers along with
date of such balance
10 Contributions made
subsequently
11 Total
12 Remarks ( if there is
dispute regarding closing
balance the figures
according to the
Government servant
should also be mentioned
in the column.)
Date : Signature