The fee for furnishing a copy of any return or part thereof shall be ten rupees or the amount to be fixed by the Government, from time to time.
RAMESH CHANDRA PANDA SECRETARY TO GOVERNMENT 2 APPENDIX FORM (See Rule 3) RETURNS OF ASSETS AND LIABILITIES OF THE CHAIRMAN, VICE-CHAIRMAN OR MEMBER OF THE ______________ DISTRICT PANCHAYAT AS ON THE ________________ Name of the ______________________ Date of election:
PART-I - ASSETS AND LIABILITIES OF THE________________________
1.
(a) Immovable property :
Land Owned Extent:
Date of acquisition:
Value of acquisition:
Leased in:
Extent:
Date of acquisition:
Value of acquisition:
Wet Dry Irrigated/dry
(b) Building Owned Plinth Area:
Date of acquisition:
Value of acquisition:
Terraced Tiled Thatched Purpose for which the building is used (commercial or residential.)
Leased in Plinth Area:
Date of acquisition:
Value of acquisition:
Terraced Tiled Thatched Purpose for which the building is used (commercial or residential.)
2. Business Interests:
(a)Shares
(b)Stock
(c)Scrip
(d)Partnership
(e)Debentures and Securities
3. Other Interests :
Bank Accounts:
4. Jewellery:
(a) Gold
(b) Precious Stones Silver ware
5. Movables (including motor vehicles)
6. Details of Trusts with which he has any connection
7. Remarks, if any of the ________(Explain the nature of acquisition of properties)
8. Liabilities 3
PART-II-ASSETS AND LIABILITIES OF HIS FAMILY MEMBERS Name of the Family member____________________________________
1.
(a) Immovable property :
Land Owned Extent:
Date of acquisition:
Value of acquisition:
Leased in:
Extent:
Date of acquisition:
Value of acquisition:
Wet Dry Irrigated/dry
(b) Building Owned Plinth Area:
Date of acquisition:
Value of acquisition:
Terraced Tiled Thatched Purpose for which the building is used (commercial or residential.)
Leased in Plinth Area:
Date of acquisition:
Value of acquisition:
Terraced Tiled Thatched Purpose for which the building is used (commercial or residential.)
2. Business Interests:
(a)Shares
(b)Stock
(c)Scrip
(d)Partnership
(e)Debentures and Securities
3. Other Interests :
Bank Accounts:
4. Jewellery:
(c) Gold
(d) Precious Stones Silver ware
5. Movables (including motor vehicles)
6. Details of Trusts with which he has any connection
7. Remarks, if any of the ________(Explain the nature of acquisition of properties)
8. Liabilities DECLARATION I,__________________ declare that to the best of my knowledge and belief the information furnished in the above return is true and complete.
Place:
Signature.
Date: