Serial Number

Description of property

Village in which the propertyPrecise location (Name of

is situated and number etc.,) District division, Taluk &

Area of land (In case of land and buildings)

Nature of land (in case of landed property)

Extent of Interest

to the Govt.Servant.If not in own name held and his/her relationship if any

Date of acquisition now acquired (whether by purchase, mortgage lease,

inheritance gift or otherwise and name with details or person/[erspmsfpr
wjem acqiored/
FORM NO. I

(Address and connection of the Govt.Servant if any with the person

persns concerned) Please see note 1 below.

Value of the property (see note 2 below)

Particulars of sanction of prescribed authority if any

Statement of Immovable Property held by Government Servant Lands, House Shope, Other Buildings Etc.

Total Annual Income from the property.

Remarks.
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (
13)
NIL

Date:

Note: Signature:
1. For purpose of column 9 the term “Lease” would mean a lease of immovable property from year to year or for an term exceeding one
year of reserving in yearly rent, where, however the leave of immovable property is obtained from a person having official dealing it
the Government Servant such a lease should be shown in this column irrespectively of the term of the lease whether it is short term,
and the periodically payment of rent.
2. In column 10 should be shown a) whether the property has been acquired by purhcase, mortgage, of lease, the prior or premium paid
for such acquisition.
3. Whether it has been acquired by lease, the total rent thereof also and c) Whether the acquisition is inheritance, give or exchange, the
approximate to value of the property so acquire.