Declaration of Assets and Liabilities

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Employee Details

Dependents (used as column headers below)

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A. Details of Movable Assets
# Description Self Spouse
1 (i) Cash
2 (ii) Deposits in banks, financial institutions and Non-banking financial companies
3 (iii) Bond, Debentures and shares in companies
4 (iv) Other financial institutions, NSS, Postal savings, LIC Policies etc
5 (v) Motor vehicles (details of makes etc)
6 (vi) Jewellery (give details of weight and value)
7 (vii) Other assets such as values of claims, interests

B. Details of Immovable Assets
# Description Self Spouse
1 (i) Agricultural lands — location(s), survey number(s), extent (total measurement), current market value
2 (ii) Non-agriculture lands — location(s), survey number(s), extent (total measurement), current market value
3 (iii) Buildings (commercial and residential) — location(s), survey/door number(s), extent (total measurement), current market value
4 (iv) House / apartments etc. — location(s), survey/door number(s), extent (total measurement), current market value
5 (v) Others (such as interests in property)

Liabilities — Loans & Government Dues
# Description Name & address of Bank/Institution/Department Outstanding Amount
1 (i) Loans from bank(s)
2 (ii) Loans from financial institution(s)
3 (iii)(a) Dues to departments dealing with government accommodation
4 (iii)(b) Dues to department dealing with supply of water
5 (iii)(c) Dues to department dealing with supply of electricity
6 (iii)(d) Dues to department dealing with telephones
7 (iii)(e) Dues to department dealing with government transport (including aircraft & helicopters)
8 (iii)(f) Other dues (if any)

Liabilities — Taxes
# Description Self Spouse
(i) (i) Income tax including surcharge (also indicate the assessment year up to filed). Give also Permanent Account Number (PAN)
(ii) Wealth tax (also indicate the assessment year up to which wealth tax return filed)
(iii) Sales tax (only in case of property business)
(iv) Property tax

C. Personal Details

Declaration