SCHEDULE-1

(See Rule 7 (3))

Return of Assets and Liabilities held by Government Servants

1 Name of the Government Servant in full :

2 Service to which he belongs :

3 Total length of Service up-to-date

(i) in Non Gazetted rank :

(II) in Gazetted rank :

4 Present post held and place of posting :

5 Total annual income from all sources

during the calendar year immediately :
preceeding the 1 st day of January 2014.

6 DECLARATION:
I hereby declare that the return enclosed, namely forms I to V are complete, true and
correct as on 31.12.2018 to the best of my knowledge and belief, in respect of information
due to be furnished by me under the provisions of sub-rule (3) of rule 7 of the Tamil Nadu
Government Servants Conduct Rules, 1973.

SIGNATURE.

Date:
Note:
1 This return shall contain particulars of all assets and liabilities of the Government Servant ,
either in his own name or in the name of any other person.

2 If a Government Servant is member of Hindu Undivided Family with coparcenary rights in the
properties of the family either as a " Karta" or as a member , he should indicate in the return
in Form No.I the value of his share in such property and where it is not possible to indicate to
the exact value of such share, its approximate value. Suitable explanatory notes may be added
wherever necessary.
 FORM - I
STATEMENT OF IMMOVABLE PROPERTY HELD BY GOVERNMENT SERVANTS
( e.g. Lands, House, Shops, Other Buildings etc.,)
IF not in
own
Precise Location name,
state in How acquired ( whether by purchase/ Particulars
( Name of District, Nature of whose mortage/lease/inheritance/gift/or other of Total
Division, taluk, Value of
village in which the Area of land ( in land ( in Extent of name Date of wise) and name with details of persons/ sanction annual
S.N Description of property Sources of Details of
case of land and case of held, and acquisitio person from whom acquired address and of income
o prpoerty property is Interest his/her ( see note Income Payments
Buildings) landed n connection of the Government servant if prescribed from the
situated and also 2 below )
property ) relationshi any with the person/persons concerned authority property
its distinctive p if any to (please see note 1 below ) if any
number, etc) the
Governme
nt servant
1 2 3 4 5 6 7 8 9 10 11 12 13 14

NOTE :

1) For purpose of column (9) the term '' lease'' would means a lease of immovable property from year to year or for any term exceeding one year or
reserving a yearly rent.however the lease of movable property is obtained from a person having official with the Government servant, such a lease should be
shown in this column of the term of the lease , whether it is short-term or long -term and the periodicity payment of rent

2 ) Column (10) should be shown :

The property has been acquired by purchase , mortage or lease, the price or paid for such acquisition.
There it has been acquired by lease, the total annual rent thereof also and the acquisition is by inheritance , gift or exchange the approximate value of
the property so acquired
DATE SIGNATURE
Remarks

15
 FORM -II
STATEMENT OF LIQUID ASSESTS HELD BY THE GOVERNMENT SERVANTS
A.Cash and bank balance exceeding 3 months emoluments
B. Deposits, loans, advances and investments ( such as shares, securities, Debentures etc., )

If not in own name,

name and address of
Name and address person in whose Annual
name held and his / Sources of Details of
S.No Description of company, bank Amount income Remarks
income payments
etc. her relationship with derived
the Government
servant

DATE : SIGNATURE

NOTE :

1 ) In column 9 particulars regarding sanctions obtained or report made in respect of the various transaction may be given.

2 ) The term 'emoluments ' means the pay and allowances received by the Government servant
 FORM -III
STATEMENT OF MOVABLE PROPERTY HELD BY GOVERNMENT SERVANTS

Price or value at the time of If not in own name, name

acquisition and / or the total
payments made upto the date of
S.No Description of item
return as the case may be in the case
of articles purchased on hire
purchases or instalment basis
and address of person in
whose name held and his/
her relationship with the
Government

1 2 3 4

DATE :

NOTE :

1) In this form information may be given regarding items like a ) jewellary owned by him (total value ) b) Silver and other
not forming part of jewellery ( total value ) c) (i) Motor cars (ii) Scooters/ Motor cycles (iii) Refrigerators/ air- conditione
other articles, the value of which individually exceeds Rs. 1000/- d) value of items of movable prpoerty individually wort
such as clothes, utensills, books, crockery etc., added together as lump sum.
2 ) In column 5 , may be indicated whether the property was acquired by purchase inheritance ift or otherwise

3 ) In column 8, particulars regarding snction obtained or report made in respect of various transactions may be given.
 FORM -III
ROPERTY HELD BY GOVERNMENT SERVANTS

How acquired with

Sources of income Details of payments approximate date of Remarks
acquisition

5 6 7 8

SIGNATURE

ned by him (total value ) b) Silver and other precious metals and precious stones owned by him
otor cycles (iii) Refrigerators/ air- conditioners (iv) radios/radiograms/ televisions sets and any
tems of movable prpoerty individually worth less than Rs.1000/- other than articles of daily use

chase inheritance ift or otherwise

pect of various transactions may be given.

 FORM- IV

STATEMENT OF PROVIDENT FUND AND LIFE INSURANCE POLICY HELD BY GOVE

INSURANCE POLICIES

Policy No Name of sun insured / Amount of Sources of Details of

S.No and date of Insurance date of annual income payments
policy company maturity premium

1 2 3 4 5 6 7

DATE :
 FORM- IV

D LIFE INSURANCE POLICY HELD BY GOVERNMENT SERVANTS

PROVIDENT FUNDS

Closing balance as
Type of Remarks ( if there is dispute
last reported by Conributions
Provident fund/ regarding closing balance of the
the Audit /
GPF /CPF Accounts officer made Total figures according to the
Account along with date of subsequently Government Servant should be
Number mentioned in the column
such balance

8 9 10 11 12

SIGNATURE
 FORM -V
STATEMENT OF DEBITS AND OTHER LIABILITIES OF THE GOVERNMENTS SERVANTS

Name & Address of Date of Details of Source of Details of

S.No Amount incurring
Creditor transaction income Payments
Liability

1 2 3 4 5 6 7

DATE : SIGNATURE

NOTE :

1) Individula items of loans not exceeding three months emoluments of Rs. 1000/- whichever is less need not be included.

2 ) In column (8 ) information regarding permission, if any obtained from or report made to the competent authority may
also be given.
3 ) The term emoluments means pay and allowances received by the Government servant

4 ) The statement should also include various loans and advances available to Government servants like advance for
purchase of conveyance, house building advance etc., ( other than advances of pay and travelling allowances advances
from the General Provident fund and loans on Life Insurance Policies and fixed deposits )
TS

Remarks

NATURE

need not be included.

petent authority may

ike advance for

wances advances