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Declaration of Assets and Liabilities: AS ON DATE/MONTH/YEAR........................

This document is a declaration of assets and liabilities form for an employee to disclose their assets, liabilities, and personal details. It requires the employee to provide details of [1] movable assets including cash, bank deposits, investments, vehicles, and jewelry owned by themselves, their spouse, and dependents; [2] immovable assets including agricultural land, non-agricultural land, buildings, houses owned by themselves, their spouse, and dependents; and [3] liabilities including loans, taxes owed, and other government dues. The employee must then provide their personal details like PAN number, date of birth, and designation before signing to declare that all information provided is true and accurate to the best

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ServeX pluS
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© © All Rights Reserved
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82 views

Declaration of Assets and Liabilities: AS ON DATE/MONTH/YEAR........................

This document is a declaration of assets and liabilities form for an employee to disclose their assets, liabilities, and personal details. It requires the employee to provide details of [1] movable assets including cash, bank deposits, investments, vehicles, and jewelry owned by themselves, their spouse, and dependents; [2] immovable assets including agricultural land, non-agricultural land, buildings, houses owned by themselves, their spouse, and dependents; and [3] liabilities including loans, taxes owed, and other government dues. The employee must then provide their personal details like PAN number, date of birth, and designation before signing to declare that all information provided is true and accurate to the best

Uploaded by

ServeX pluS
Copyright
© © All Rights Reserved
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Declaration of Assets and Liabilities

AS ON DATE/MONTH/YEAR.........................

I,……………………………………………………., son/daughter/wife of …...………………………………,

aged……………years, belonging to ……………………………………....................office/cadre/

service and presently working as(Designation)................................. give herein below

the details of the assets (immovable, movable, bank balance, etc.) of myself, my

spouse, our children and dependants[#}:

A. Details of movable assets


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

Sl. Description Self Spouse Dependant-1 Dependant-2 Dependant-3


No. Name(S) Name Name Etc. Name
(i) Cash

(ii) Deposits in
Banks, Financial
Institutions And
Non-Banking
Financial
Companies

(iii) Bonds,
Debentures and
Shares in
companies

(iv) Other financial


institutions,
NSS, Postal
Savings, LIC
Policies, etc

(v) Motor Vehicles


(details of
make, etc.)

(vi) Jewellery (give


details of
weight and
value)

(vii) Other assets,


such as values
of claims /
interests

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
companies should be given.
[#} Dependant here means a person substantially dependent on the income of the
employee (include children, parents, unmarried & dependent sister/ minor brothers
(handicapped) solely dependent on the employee.
B. Details of Immovable assets
[Note: Properties in joint ownership indicating the extent of joint ownership will also have to
be indicated]
Sr. Description Self Spouse Dependant-1 Dependant-2 Dependant-3
No. Name(S) Name Name Etc. Name
(i) Agricultural Land
- Location(s)
- Survey number(s)
- Extent (Total
measurement)
-Current market value
(ii) Non-Agricultural Land
- Location(s)
- Survey number(s)
- Extent (Total
measurement)
-Current market value
(iii) Buildings (Commercial
and residential)
Location(s)
- Survey /door
number(s)
- Extent (Total
measurement)
- Current market
value
(iv) Houses / Apartments,
etc.
- Location(s)
- Survey /door
number(s)
- Extent (Total
measurement)
- Current market
value
(v) Others (such as
interest in property)

(2) I give herein below the details of my liabilities / overdues to public financial
institutions and government, dues to others:-
[Note : Please give separate details for each item)

Sr. Description Name & address of Bank / Amount outstanding as


No. Financial Institutions(s) / on …………………..
Department (s)
(a) (i) Loans from Banks
(ii) Loans from financial
institutions
(iii) Government Dues:
(a) dues to departments
dealing with government
accommodation
(b) dues to departments
dealing with supply of
water
(c) dues to departments
dealing with supply of
electricity
(d) dues to departments
dealing with telephones
(e) dues to departments
dealing with government
transport (including
aircraft and helicopters)
(f) Other dues, if any

(b) (i) Income Tax including


surcharge [Also indicate
the assessment year upto
which Income Tax Return
filed. Give also Permanent
Account Number (PAN)]
Attach copy of ITR filed for
the last 3 years
(ii) Wealth Tax [Also
indicate & attache copies
of the assessment year
upto which Wealth Tax
return filed.]
(iii) Sales Tax [Only in
case of proprietary
business]
(iv) Property Tax –
a. Remitted
b. In arrears, if any
C. Personal Detail

EPF/ESI/PAN No. :-

Gender :- (M/F)

Date of Birth :-
(DD/MM/YYYY)
Place of birth :- ______________________________________

Class/Group :- :-

Cadre :-

Home District :-

I hereby declare that the above details are true to the best of my knowledge
and belief.
Signature ____________________________

Name of Employee:_____________________

Place:______________ Designation:__________________________

Date:_______________ Department:__________________________

Note: Please sign each page of the declaration. Asset declaration form
must be in A4 size white paper with computer typed (single side)
in prescribed format.

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