lok pal form

8/11/2019 Lok Pal Form

1/8

APPENDIX - II

[(Rule 3 (I)]

Form No.1

Details of Public servant, hisher s!ouse an" "e!en"ent chil"ren

Sl.No.

Name Public positionheld, if any

Whetherreturns beingfiled by him /her, separately

1 Self 2 Spouse

3 ependent 1

! ependent 2

" ependent 3

# ependent !

ate$ Signature$%%%%%%%..


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3/8


4/8

F&'( N&. )))

Statement of immo*able property on first appointment or as on the 31st (arch, 2+....e.g. -ands, ouse, Shops, &ther uildings, etc.0

eld by Public Ser*ant, his/her spouse and dependent children

Sl.No.

escription of property-and/ ouse/ Flat/Shop / )ndustrial etc.0

PreciselocationName ofistrict,i*ision,alu4 and

5illage in6hich theproperty issituated andalso itsdistincti*enumber etc,0

7rea of landin case ofland andbuildings0

Nature of landin case oflandedproperty

89tent ofinterest

)f not in nameof publicser*ant, statein 6hosename heldand his/her

relationship ifany to thepublic ser*ant

ate ofac:uisition

o6 ac:uiredWhether bypurchases,mortgage, lease,inheritance, gift orother6ise0 and

name 6ith detailsof person /persons from6hom ac:uiredaddress andconnection of the;o*ernmentser*ant, if any06ith the person /personsconcerned0Please see Note1 belo60 and costof ac:uisition.

Present *alueof theproperty ife9act *aluenot 4no6n,appro9 *alue

may beindicated.

otal annualincome fromthe property

remar4s

1 2 3 ! " # < = > 1+ 11 12

ate$ Signature$

Note$ 10 For purpose of column >0 the term ?lease@ 6ould mean a lease of immo*able property from year or for any term e9ceeding one year or reser*ing a yearlyrent. Where, ho6e*er, the lease of immo*able property is obtained from a person ha*ing official dealings 6ith the ;o*ernment ser*ant, such a lease should besho6n in this Aolumn irrespecti*e of the term of the lease, 6hether it is short term or long term and the periodicity of the payment of rent.


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6/8

Form No.))

Statement of mo*able property on first appointment or as on the 31 st(arch 2+%%.

etails of the mo*able assets of self, spouse and dependent children

Sl.No.

escription 7mount in 'upees

Self Spouse ependent1

ependent 2

epend 3

i0 Aash in hand

ii0 etails of deposit in an4account F's, ermeposits and all other typesof deposits including sa*ingaccounts0. eposits 6ith

financial institutution, NonBan4ing financialAompanies and AoBoperati*e societies and theamount in each such deposit

Name of an4 /Financialinstitutions CNature of

eposit

iii0 etails of in*estment inonds, debentures / shareand units in companies /mutual funds and others.

Name of company

i*0 etails of in*estment inNSS, Postal Sa*ings,)nsurance policies andin*estments in any Financialinstrument in Post &ffice or)nsurance Aompany

Name of )n*estment

*0 etails of deposits in

Pro*ident Fund / Ne6Pension Scheme

Name of

)n*estment


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*i Personal loans /ad*ancegi*en to any person or entityincluding firm, company,trust etc. and other recei*ables from debtorsand the amount e9ceeding

a0 t6o months basic pay6here applicableb0 'upees one la4h in othercases0

Name of thedebtor

5ii (otor *ehicle/7ircrafts/Dachats/Shipsdetails of (a4e, registrationnumber etc. year of purchase and amount

Nature of *ehicleregistrationNo. C year ofpurchase

*iii Ee6ellery, bullion and*aluable things0

gi*e details of 6eight0

;old

Ee6ellerySil*er

Pre*iousstones/preciousmetals

ullion ;old

Sil*er

Preciousstones /preciousmetals

)9 7ny other assets

ate$ Signature$

Note# $# 7ssets in oint name indicating the e9tent of oint o6nership 6ill also ha*e to be gi*enNote $2$ )n case of deposits/in*estments, the details including 7mount, date of deposit the scheme,Name of the an4/)nstitution and ranch are to be gi*en.Note# 3$ 5alue of onds/share debentures as per current mar4et *alue in stoc4 e9change in respect oflisted companies and boo4 *alues in case of unlisted firmsNote!$ etails including amount is to be gi*en separately in respect of each in*estmentNote %#Gnder ic0 details of mo*able assets not co*ered in i0 to *iii0 abo*e *aluing indi*idually o*er t6omonths basic pay 6here applicable or 's. 1 la4h may be indicated.


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Form No. )5

Statement of derails and other -iabilities on First appointment or as on 31st(arch 2+%%%.

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