“Form – IV (see rule 7) Statement of Assets and ... - Lokayukta

“Form – IV(see rule 7)Statement of Assets and Liabilities filed by ..............................................................................................................................................................(herespecify the name and designation of the Public Servant) for the financialyear ending 31 st March.................................(Note :- Every column appearing in the form has to be filled in wordsnot by dashes and dots)1. The permanent address(with Telephone no andMobile no. if any) of thepublic servant2. Names of the members ofthe Family of the publicservant and his relationshipwith each of them (Reg.`Family`, see explanation tosection 22 of the LokayuktaAct)3. Present annual income ofthe public servant and eachone of the family membersNote: Statement of Assets and Liabilities of the public servant and hisfamily members (“family of a public servant” means the spouse and suchchildren and parents of the public servant as are dependent on him / her):4. Cash and other Liquid Assets as on 31 st March .............

Particulars to befurnishedPublicServantSpouseDependentFatherDependentMotherDependentChildren1 st 2 nd 3 rd(a) Cash(1) (2) (3) (4) (5) (6)i) Cash on handii) Cash kept in locker(give details)iii) Whether it ispersonal savingsiv) If not, mention thesource of acquisition(b) Bank depositsi) Account / CertificateNo. nature of deposit,amount and name &branch of bankii) Whether it ispersonal savingsiii) If not, mention thesource of acquisitioniv) Date of deposit(c) Bank Accountsi) Account No. &nature of A/C amountand name & branch ofbankii) Whether it ispersonal savingsiii) If not, mention thesource of acquisition(d) Post OfficeAccounts

i) Account /CertificateNos nature of deposit,amount and name &place of Post Officeii) Whether it ispersonal savingsiii) If not, mention thesource of acquisition(e) National SavingsCertificates and otherCertificatesobtainedthrough the PostOffice,i) No, of the NSCs andothercertificates,amount, name & placeof post officeii) Whether it ispersonal savingsiii) If not, mention thesource of acquisition(f) Units of UnitTrust of Indiai) particulars of units,name of the branchand amount.ii) Whether it ispersonal savingsiii) If not, mention thesource of acquisition(g) Government andother Securitiesi) Particulars ofsecurities, name &place of office of

Government /Company and amountinvestedii) Whether it ispersonal savingsiii) If not, mention thesource of acquisition(h) Shares,Debentures orDeposits inCompaniesi) Particulars ofshares, debentures ordeposits in companies(furnish address ofcompany) and amountinvestedii) Whether it ispersonal savingsiii) If not, mention thesource of acquisition(i) Money advancedto others as loan orotherwisei) Amount, date andname of the person towhom the money isadvancedii) Whether it ispersonal savingsiii) If not, mention thesource of acquisition(j) Insurance Policies

and Provident Fundsi) Particulars ofInsurance Policies andProvident Fundsii) Whether it ispersonal savingsiii) If not, mention thesource of acquisition(k)Otherinvestments andbeing investments inimmovable property(i) Particulars ofinvestments, name &address of companyand the amountinvestedii) Whether it ispersonal savings(iii) If not, mentionthe source ofacquisition5. Moveable property other than that covered by Item 4 as on 31 st March...........(a) Jewellery andBullioni) Particularsii) Cost and date ofacquisitioniii) Whether it is out ofpersonal savingsiv) If not, mention thesource of acquisition

(b) Vehiclesi) Particularsii) Cost and date ofacquisitioniii) Whether it is outof personal savingsiv) If not, mention thesource of acquisition(c) Antiques beyondthe value ofRs. 10,000/-i) Particularsii) Cost and date ofacquisitioniii) Whether it is outof personal savingsiv) If not, mention thesource of acquisition

d) Silverwarei) Particularsii) Cost and date ofacquisitioniii) Whether it is outof personal savingsiv) If not, mention thesource of acquisitione) Investments inBusiness Concernsi) Particularsii) Cost and date ofacquisitioniii) Whether it is outof personal savingsiv) If not, mention thesource of acquisitionf) Other Householdgoods includingfurniture costingmore than Rs.25,000/-each

6. Immovable Property as on 31 st March .............a) Agricultural landsi) Survey No. andplaceii) Extentiii) Whether dry, wet,garden or plantationlandiv) Whether ancestral,joint or separatepropertyv) If not, mention thesource of acquisitionvi) Cost and date ofacquisitionvii) Whether it is outof personal savingsb) Non-agriculturallands which have notbeen built uponi) No, assigned to theland and place wheresituatedii) Extentiii) Whether ancestraliv) Cost and date ofacquisitionv) Whether it is out ofpersonal savingsvi) If not, mention thesource of acquisition

c) Buildings(including flats)i) Complete address ofthe buildings withdimensionii) Cost and date ofacquisitioniii) Whether ancestral,joint or separatepropertyiv) Whether it is out ofpersonal savingsv) If not, mention thesource of acquisitiond) Other immovablepropertyi) Particulars of otherimmovable propertywith dimensionii) Cost and date ofacquisitioniii) Whether ancestral,joint or separatepropertyiv) Whether it is out ofpersonal savingsv) If not, mention thesource of acquisition

7. Liabilities as on 31 st March...........a) Nature, extent andother particulars ofliability and the datewhen it was incurredb) Name and addressof the person to whom(creditor) liableI, .....................................................................................do hereby solemnlydeclare that the information furnished above is true and that nothing relevant hasbeen omitted therefrom.Station:Date :Signature of the Public ServantDesignation .............................