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 APPENDIX FORM (See Rule 3) RETURNS OF ASSETS AND LIABILITIES OF THE CHAIRMAN, VICE-CHAIRMAN OR MEMBER OF THE _______________ PANCHAYAT UNION COUNCIL 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
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: