DeclarationofAssetsandLiabilities

Year.........................
I,.,son/daughter/wifeof...,
aged.. years, belonging to .....................
service

and

presently

working

as

................................. give herein below the details of

the assets (immovable, movable, bank balance, etc.) of myself, my spouse and
dependants*:
A.

Detailsofmovableassets
(Assets in joint name indicating the extent of joint ownership will also have to be

given)

Sr.
No.

Description

(i)

Cash

Depositsin
Banks,
Financial
InstitutionsAnd
NonBanking
Financial
Companies

Bonds,
Debenturesand
Sharesin
companies

Otherfinancial
institutions,
NSS,Postal
Savings,LIC
Policies,etc

MotorVehicles
(detailsof
make,etc.)

Jewellery(give
detailsof
weightand
value)

Otherassets,
suchasvalues
ofclaims/
interests

(ii)

(iii)

(iv)

(v)

(vi)

(vii
)

Self

Spouse
Name(S)

Dependant1
Name

Dependant2
Name

Dependant3
Etc.Name

Note: Value of Bonds / shares / Debentures as per the latest market value in Stock
Exchange in respect of listed companies and as per books in the case of non listed
companiesshouldbegiven.

* Dependant here means a person substantially dependent on the income of the

employee.
B.
DetailsofImmovableassets
[Note: Properties in joint ownership indicating the extent of joint ownership will
alsohavetobeindicated]
Sr.
No.

(i)

(ii)

(iii)

(iv)

(v)

Description

AgriculturalLand
Location(s)
Surveynumber(s)
Extent(Total
measurement)
Currentmarketvalue
NonAgriculturalLand
Location(s)
Surveynumber(s)
Extent(Total
measurement)
Currentmarketvalue
Buildings(Commercial
andresidential)
Location(s)
Survey/door
number(s)
Extent(Total
measurement)
Currentmarket
value
Houses/Apartments,
etc.
Location(s)
Survey/door
number(s)
Extent(Total
measurement)
Currentmarket
value
Others(suchas
interestinproperty)

Self

Spouse
Name(S)

Dependant1
Name

Dependant2
Name

Dependant3
Etc.Name

(2)
I give herein below the details of my liabilities / overdues to public financial
institutionsandgovernmentdues:
[Note:Pleasegiveseparatedetailsforeachitem)

Sr.
No.

(a)

Description

(i)LoansfromBanks
(ii)Loansfromfinancial
institutions
(iii)GovernmentDues:
(a)duestodepartments
dealingwithgovernment
accommodation
(b)duestodepartments
dealingwithsupplyof
water
(c)duestodepartments
dealingwithsupplyof
electricity

Name&addressofBank/
FinancialInstitutions(s)/
Department(s)

Amountoutstanding
ason..

(b)

C.

(d)duestodepartments
dealingwithtelephones
(e)duestodepartments
dealingwithgovernment
transport(including
aircraftandhelicopters)
(f)Otherdues,ifany

(i)IncomeTaxincluding
surcharge[Alsoindicate
theassessmentyearupto
whichIncomeTaxReturn
filed.GivealsoPermanent
AccountNumber(PAN)]
(ii)WealthTax[Also
indicatetheassessment
yearuptowhichWealth
Taxreturnfiled.]
(iii)SalesTax[Onlyin
caseofproprietary
business]
(iv)PropertyTax

PersonalDetail

GPF/CPF/PRANNo. :

Gender

(M/F)

DateofBirth

Class/Group

Cadre

(FullNamee.g.B.A.S.BiharAdministrativeService,
B.S.S.BiharSecretariatServiceetc.)

HomeDistrict

I hereby declare that the above details are true to the best of my
knowledgeandbelief.

Signature..........................................
NameofEmployee:............................
Place:.......................

Designation:......................................

Date:.......................

Department:..........................................

Note:

Pleasesigneachpageofthedeclaration.Assetdeclarationform
mustbeinA4sizewhitepaperwithcomputertyped(singleside)
inprescribedformat.