"'11'>1'111

ICAR

ICAR-Central Tobacco Research InstituteDr.N.C.Gopalachari Road, Bhaskar Nagar, Sriram Nagar Post

RAJAHMUNDRY -533105, A.P., INDIA

Web-site:www.ctrLorQ.inPBX Phones: 0883-2449871-74; FAX: 0883-2448341; Director (0): 0883-2448995

Director FAX: 0883-2410555; SAO (0): 0883-2448341; E-mail: ctri ap@nic.in

(An ISO 9001 :2008 Certified Institute)

~;;;-,

(/1;/ ...;"~

.I(~]I!I _I

~~~,~J!<~~~I~\'~~

¥,

- F.No.1(8)(TR)/2018-19/Adm.1 Date 02.08.2018 .

FINAL RESULT (FROM RESERVE LIST) OF TECHNICAL ASSISTANT (T-3) EXAMINATION - 2016

(Conducted by Agricultural Scientists Recruitment Board, New Delhi)

Basing on the approval of the Competent Authority of the Agricultural Scientists Recruitment Board,

New Delhi, the ICAR-CTRI, Rajahmundry declares the final results (Reserve List) of Technical Assistant

(T-3) Examination-2016 conducted on 17.07.2016 by Agricultural Scientists Recruitment Board, New Delhi

for filling 6 positions of Technical Assistants (T-3) at ICAR-CTRI, Rajahmundry and its Research Stations.

The Category-wise reserve list of candidates as approved by the ASRB vide Lr.No.F. 5(55)/2017-CC-II,

dated 1th April, 2018 is presented herewith for information of all the candidates.

The Offer of appointment (Memorandum) to 6 candidates in the select-reserve list will be sent to

their respective addresses as provided in their applications. The required proformae as mentioned in the

Memorandum, may be downloaded from this institute website Le.( www.ctri.orq.in) and submit the same

personally duly filled in all respects alongwith original certificates for verification of records at ICAR-CTRI,

Rajahmundry on or before 27.08.2018.

ICAR-CTRI reserves the right to modify/withdraw the enclosed select-reserve list, if any

discrepancy noticed by this Institute.

~~o;,(B. SWARNA KUMARI)

SR.ADMINISTRATIVE OFFICER

Ene!.: As above

Copy to The Officer-in-charge, AKMU, ICAR-CTRI, Rajahmundry for uploading the above

notification with enclosures in the ctri-website.

Cont. page 2..

---~ -

To

The Director, ..

ICAR-Central Tobacco Research Institute,

RAJAHMUNDRY-533 105(AP).

Sir,

With reference to your Offer of Appointment No.F.,

, I submit that I am willing to .accept the offer of appointment to the post of Technical Assistant(T-3)(Field/Farm)

(Category-II) under UR/SC/ST/OBS/ESM/PHCon the terms and conditions stipulatedtherein.

I also submit that I am not serving or is under obligation to serve another

Central/State Government or public authority or any foreign government,

negotiations for which are already in progress: I also submit"that I have not applied

or is being considered for the post elsewhere.

Three sets of the following forms duly filled in all manner are enclosedherewith for kind verification and approval of Appointment Order.

1. Attestation form

2. Certificate of Physical fitness

3. Certificate of Character

4. Form of Oath of Allegiance

5. Declaration of marital status

6. Home Town declaration

7. Return of Assets & Liabilities on first appointment

Yours faithfully,

Station:

Date Name(in block letters)Mobile No.:

Email id

Postal Addre~s:

::2::

1~IName of the Institute I ICAR-CENTRAL TOBACCO RESEARCH INSITTUTE---r_~ RAJAHMUNDRY-533 105 (AP) _ _ jCategory wise vacancy Technical Assistant (T-3): Total: 6 posts

position

-

Note:

. Offer of Appointment (Memorandum) will be valid subject to production of original certificates viz

Education, Date of Birth, Caste Certificate etc. ( as mentioned in the Memorandum).

. Place of posting will be decided basing on the choice as given by the candidate in his/her

application form.

(General: 4, OBC-1, SC-1,)

Rajahmundry(AP), Kandukur(AP), Vedasandur(Tamil

Nadu), Hunsur(Karnataka) .

- ---- -

lal Group (with Agricultural Related Subject

f--- (Field/Farm & Lab) : Code 01IS. Name of the Name of Father / Roll No DaB Gender Category I MarksI No Candidate Mother (M/F) under of theI

Mr./Ms. Sri/Smt. GEN /SC / candidOBC ate in

theexam

t-- I1 2 3 4 5 6 7 8 I

- -- -- - 1- I1 MIT KUMARBHARAT KUMAR I

BHATOREBHATORE

240100704 08-06-87 M GEN 69 II

:;: NUGULACHAITANYA--+- - - - --

ENUGULA ARJUN 240100745 02-06-90 M GEN 68KUMAR RAO

- - I-

3 AASI DIVYA AASI UMAPATHI240101644 19-08-92 F GEN 68

REDDYI

I 4TRINADHPOLISETTY

VV240101769 22-04-86 M GEN I

;JSATYANARAYANA

IL5 VENKATA VENKATESWARLU,

SARADHIKUMAR, T THANNIRU240100334 04-07-86 M OBC 67

-h6-!6 ARVIND, I. DEVADAS, I. 240100761 14-03-80 M SC

--- -

...

Downloading of following Formates from this institute website www.ctri.org.in by

Selected Candidates under Reserve Panel for the post of Technical Assistant(T-3) and

submit the same to ICAR-CTRI,Rajahmundry for verification of certificates on

27.8.2018 -reg.

,- 1. Form of Acceptance of Technical Assistant (T-3) post.)

2. Attestation form

-

3. Certificate of Physical fitness

4. Certificate of Character

5. Form of Oath of Allegiance

6. Declarationof marital status

7. HomeTowndeclaration

8. Return of Assets & Liabilities on first appointment

--

,-

UWAmrn~

-

I Affix~;i;~ed pass- I

I port,size (5.cm. x It 7 em. approx.) copy'I of recent photo- I

I graph where asked 1, for. I1 ~

ATTESTATICN~

The furnishing of' false information orsuppression of any factual information-in the Attestation Form would be a dis-qualification, and is likely to rends:!"the canG.ldate 'U.L!5'1...;. i;Cl' C;I..plGy11leut 1.1,,"'del"the Government 0 .

,2. If detained, arrested, prosecuted,bound dawn, fined, convicted, debaredacquitted etc. subsequent to thecomple-tion and submission of this form, the -dotails shou1d be' communicated immedia-tely to the authori t:.os to whom the attes-tation form 'has been sent early, failingwhich it will be deemeQ to be a suppressionof factual information.

3. If the fact thn t false informationhas ,been furnished or that there has -been suppression of any fa,ctual infor-mation in the attestation form comes tonotice a t any time during the serviceof a person, his services wlfluldbe liableto be. terminated".

2. Namein full(in 1

block capitals) I

with aliases, if ,BDY'. 1

(Please indicate if :1you have added or ,dropped in any stage,

any part of your name ,or sUrname. r

,

SURJ."f AMB NAME1

,,tWI

,

,-.-

20 Present adres s in full(i .e . Village, Thanaand District, or HouseNumber, Lanel$treet/Road and TO\ffi.)

30 a)Home Address in full(i.eo, Village, Thana,and D1strict, or HouseNumber, Lane lStree t/Road and Town and nameof District Headquarters 0

b)If Originally a resident ofPakistan, the address inthat countryand the date ,

of migration to Indj.fltlUniono

~o.e:Cl2"Qoe.o()

--- -- -.- -----.

. j

, .

~ Z to

4 Part:!. cularsof places (y'" th peri'ods of residences) whereyou have resided for more than one year at a time during8he preceding five years.. In case of stay ab;:'04d (inclu..ding Pakistan) particulars of all places "Thora YOIl have .resided for mpre th~n 0~$ yc~r aft~~ ~t~~ining the age of2~ years should be given. 'if

.From T,o Residential address

in full (i.e. villageTh~na and Distt. orHouse No~ Lane/Street/Road and Tcwn.)

Name of the DistJ.':Headquarters of tlplacementioned itthe preceding co~

-,------....-.--.----

in"

~ .~.

5. Narne Nationali tyby birth &/or by domi-cile)

:P:k'\ce 'Occupa-Present"f: tion (if _"Jostal

B~rth employ- Addressed Give (if deaddesigna- give lasttion & a~u..i:c'::;s)'offj.cialaddress"

:PermnentHorr.eadd..ress

5.(a) '-Information to b9 f1.l:rnirhr-;d Mi~3 J"sgr:>d to 3011(S) and/or dteres) in case they <:t:i.'es L;udjir4:;!living in a foreign count

II....f_- ."

i) Fa ther

...-.... .-(name in fUlllaliases, ifany)

ii) Mother

lii) Wife/HusbandIv) Broth:;r( s)

v) Sister(s)...0'. ,,

.:A '.

-

~-----

-.---

131

~ Wionalitbirth and/odomociie

Place of

birth - =~~~d iwith full address

~a te from

~~J~~-in the countrv

mentione~p.reviouscolumn .

~.

-

--9. a) Your religion

b) Are.you a member of aScheduled Caste/Schoduled Tribe?Answer 'Yes. or No'

10. '»iucational Qualification showing places of education withyears in Schools and Colle!'es since l5th Year of age.

tDate of.

f leavingI

.r.

,

,,

Eamination

pas sed.

Naiiie of Schoo17

College .with fulladdress.

jDa te ofI enteringI.r.

-J

-"

6. Nationality

----.---7. a) Date of birth al)

b) Present age b)c) Age at Matriculation' c)

.

8. a) Flace or birth, District(a) --

_I) and state ';l.nwhich situa-

ted --, '"

b) District nd State to

which you belong (b)

c) District and State to

which YOUr father 'origi(c)

nally belong"

~

I

I

I

II

II

I

I

~

I

I

I

I

-

"

li.. ,

l\.) kr:B you. holding 01' :1r.:,VC 2.n~" !:;i~'Z hGl::!. 3.2 appoln.t;msr:.t.under the Central or State Government or a semi-Govern..

ment or a Quasi-Government body, or an autonomous body l'

or a public undertaking, or a private firm or institutlon?

if SOt givG full particulars with dates, or employment,up-to...date.

FromPeri ad

To

'--Designation, Full nameemoluments and -and adiress

nature or employ-of empJoyermente

ReaS ons :Oor'

leaving. previous

servicQ.~

.

IJ.. (B) If the previous emplcvncnt was ttlide~_the Government C}f

Ind1a, a State Government/an undertaking owned ~£n-tJ:.Q..lled .~ the CLoverIlffi.olli.-9fIn<!ia or a St.:"te Govem-ment EfJd !ii:i!{xnxrocEt~x~h"lxr::::EJliSxxIanAutonomous B<:J4yl

U~i versi ty/Local Bodv. .

If'you had left service on giving a monthts noticeunder rule 5 of the Central. Civil Serviccs(Temporary

Service) Rules, 1965, or any similar corresponding ruleswe~e any disciplinary jroceedings framed against you,

or hRd you been called upon to explain Youl'conduct

in any. matter at the Urne you gnve notice of termination

of service, or at a,subsequent date, before your serviceactually terminatedo .

----12 (i) been arres ted?

been prosecuted?been kept under detGn~

tion?d) Have you eVGr been bound down?e) Have you ever been fined by a court

Lawf) Have you ever beenfovicted.by a

court of la\oJ'for any offenc~?

g) Have you ever been <lebar,red" from ,anyexamination or rust~cateabyanyUni-versity or any oth~T. educational authQ-rity/institution? .Yes/No

h) Have you ever been debarred/disqua-lified ~py aby FUblicService.CommissionStaff Seclection Ccr'111lission for any of

its examination/selection? Yes/No

i) Is any cnse pending against you inany court of law at the time of fillingup this AttestatimF0rm? . Yes/No

j) Is any case pendL"lg agains t y'm inany University or ~~y other educationauthorityPinstitutlv;~t'.t. the time of

filling up thi~ Attest~tion Form? Yes/No

a) 'Have you ever

b) Have you everc) Have you ever

Yes/NoYes/NoYes/No

Yes/Noof

Ye.sINo

Yes/No

! ~

...580...

----.

\,;\

z 5-

-

k) Whether discharged/expelled/withdrawn Yes/No'from any training -ins ti tut1. on under theGovernment or othwerwisQ

If the answer to any of the above mentioned questions -is rYes' gi'lr8 fullpal,t;iculars of the c as e/arres tide ten-tion/fine/conviction/sentence/pllnish111£~nt etc. and/or th.e.nature of the case pending tin the Caurt/University/Educa-,ti onal Authori ty e tc ., at tho timG of filling up this form.

~: i) Please also see the rwearingl at the top of thisAttestation Form.,

ii) S~cificanswers to each of the' questions should be . ,

givin'by striking Ollt 'Yes' or 'No' as. the ca.se may be.

ii)~

-

r ____

\). 1.()()

!

2.

13. Names of two responsible persons ofyour locali~ or two references towhomyou are known.

I certi'ry that. the foregoimg information isc,mplete,..to the b,est of my knvwledge and belief.of Rny ciraumstances whic~Limpair.my fitness forunder Government.

correct andI am not aware

employmentL might

Signature of the candidate

r ..1..........JJ (~. IJ\J .

'Pla-ce "

. . . . . ,<0.,0 ~6-. 0 4) ~ 00.

.:..;

- - .,

!.DI""I'l'lTY CERTIFICATE

(Certificate to be signed by anyone of the following)

Gazetted Offic9rs or Central or State G~vernment;l-~embersof Parliament. cr State legislature belongingto the c~nstitutency where the candidate or his parenti

guardiaa is o~dinarily resident;Sub-Divisional Magistrates/Officers;

'IeJhsildarsor Naib/Deputy Tehsildars authorised to

exerc1semagisterial powrs;Prlncipal~ead-MastGr or the r6cognisod School/College/

Inst~tution' where the candidate studied ).ast;BlGcl;{ Development Officer; ','

Fost-Masters; ,

Panchayat Inspectors.

6:

~

.

Certified that I have Im'JWnSri/Jmt/Kum~

son/daughter of Shri

.....-

----

,~_.~. forth3 last ___ years

months and that' to the; best of' my lmowledge ~ndI

belier the particulars fUl~ished by him/her are correct.

Date;

nace:

Signa tl1.ro s

Designation or status and address.

TO BE FILEED BY THEOFFICE:--- ,.....------

i) Name, designation and full addressof the appointing authorit-y

ii) Post for which toe candid~te isbeing c0nsideredo

ts/6/5/88

~~I

,-

'. -

i)

-ii)

I

iii):Lv)

v)

vi)viiviii)

r"""'I

CERTIFICATE OF PHYSICAL FITNESS

,By a Single Medical Officer/the Civil Medical Head)

I/We do hereby certify that I/We have examined

Sr iISmt. /Kum. a candidate

for emplovment in the

~. Department and cannot discover that he/she has any disease

-constitutional effect or bodily informity except

I/We do not consider this a disqualification for

employment in the Office of

He/She is free from communicable diseases.

His/ReI' age is according to his/her own statement

Years and by appearance about Years. He/She has marks

of Small Pox/vacoinatlon.

Personal marks of identification:

1)

2)

Signature of the candidate

Date: SIGNATURE AND DESIGNATION

nsn/*

-

CERTIFICATEOFCHARACTER(For Class IIIServices)

Certified that I have known Sri/Smt./Kum. ~

., ~f"(1 ')f ';ri_ .-- -- - -~--for th~ last years__ -

Months a,ndthat to the best of my knowledge and belief hebetlis reputable

character and has no antecedents which render him unsuitable for Government

employment.

Sri/Smt.lKum..." is/is not related to me.

SIGNATURE:.-DESIGNATION:

'"

"(To be attested by Stipendiary I Class Executive Magistrate, District Magistrateor Sub-Divisional Magistrate)

ATTESTED:

SIGNATURE:

Place:

Date: DESIGNATION:

(Attesting Authority)

.This should be done after the candidate hasbeen finally selected for

appointment.

~.

...,.

--

._------

j>

~I

'J{rr~frLj (iJf~'{ST0Rf-ft~ t~.' G""

""'-'-,1 -'\... ' ry~,_r" -'-:; ~ '<.,..-rq ,q'";?,...:: ",', ~.: '~I '-1 '_! . \ . "-! . !

,

.~_.~ ' ,--- - ---'~"-'--

INOliHJ ~:JUi\JCIL. OF I~GrUCULTUHi'lL RESEARCH

. [(~.r_fTI_9X_Q_~j:Jl.E.L.ALl.:~£L4:.a-'l.C-~~-c}'

t hS_.£.<?.!:1sti..t.uiion 0 f I.nd ~Q.

II 'q' m~ ffi:IT ~ /

~ 1''''1~o I B ghr;tITCp~,-IT (Fc-f. ~. ~rf(1 Jrh ftrPcTITIT ~~I 14\1

'-1TT"(l ~ BfqC:.~ c1;g-'Gl~m:T ~m ~r !.,~()1 T111 p -q- ~Tf-nl <fr

IT"'-"BI -3frT 13T~\'?\11 -31~"F1JTT~~Tr C1tIT -q' ~ q-~ ;$" cj><fco!..!1~ q, I TTVf-.~ j'l I >,J C\ 11

~fcK1 ~~ I ~G.Tfr -3ltr l~-{S1:fffiTB ~ %tIT I

. ~ 0K1: ~nrr 'ern BQI <-leiI' Cfit '~

II I O.O~O. do swear';

solemnly afFirm thAt I will be F3ithfulana ~~OL true allegiance to

I nd ia ,3nd ta the Canst Hut ,Lo:-! of lrid i2 a s by lall! est8bl ishsd 1 t,hat

I will uprold, the Sovereignty and' integrity of India v and that I will

carry aut the duties of'my office loyally, honestly and' with im~ar-

tii:11ityll.

(So 11e1p, me God)

""f~:

Place;

f~:Oat8 &

QKfrl:1f

5IGNiHURE;

')

--.-

DECLARATION

TSri/Smt/Kum/ ,,_.~-------- ~-_.._-

Declare as under:

*i) That I am un-marriedla widower/a widow.-

il) That 1am :alamed and have 0;:11ycne spcase ii. ing.

.

iii) That I have entered into or contracted a marriage with person having a

spouse living. Application for grant of exemption is enclosed.

iv) That I have entered into and contracted a marriage with another person duringthe life time of my spouse living. Application for grant of exemption is enclosed.

2. I solemnly affirm that the above declaration is true and I understand that in theevent of the declaration being found to be incorrect after my appointment, I shall beliable to be dismissed from service.

SIGNATURE

DATE:

* NOTE: Please delete clause/clauses not applicable.

--

'2~

Extract from Office Memorandum No.4311/55-Estt.(A)/Part.lI, dated the 11thOctober. 1956 from Ministry of Home Affairs to all Ministries of the Governmentof India etc.,

.\(4) The term "home" referred to in this OffICeMemorandum shall be the

permanent home town Dr villageas entered in the Service 'Book or otherappropriate officialrecord of the Government Servant concerned, or suchother place as has been declared by him, duly supported by reasons,(such as ownership of immovableproperty, permanent residence of nearrelatives for example, parents, brothers etc.) as the place where he wouldnormally reside but for his absence from such a station for service inGovernment. Persons "displaced"from territoriesnow part of Pakistan orthose who have recently acquired an Indian domicileor those who havenot so far declared their homes for any purpose in correspondence withthe ~ov~rnment, for example, service records, applications for housebuilding advances, etc., should now make a formaldeclaration. In everycase the declaration should be made to the authority who has beendeclared to be the controlling offICer in respect of the GovernmentServant for purposes of traveling allowance claims. It should reach thatauthority not Jater than six months from the date of this order or on a dateprior to the. availing of the concession under this office memorandumwhichever is earlier date. In the case of a Government Servant on

ForeignService,the periodofsixmonthsshallbe reckonedfrom the dateof his rev.ersionto GovernmentService unlessthe concessionis E.ixtendedto him duringhis ForeignService,in which case a declarationshall bemade within six monthsof the date of whichit is decidedto extend theconcessionto him.

~. -

A declaration of "home" once made shall ordinarily be treated as final, but

in exceptional circumstances the Head of the Department or .if theGovernment Servant himself is the Head of the Department, the

Administrative Ministry may authorize a change in such declarationprovided that such a change shall not be made more than once during theservice of a Government Servant.

DECLARATION OF HOME TOWN

I hereby declare that the Home Town where I woutd normally reside but

for a bsence for service is the 1ewn/villajJe

TaluklMandal in State.

Signature:

Designation:

I II

. .;.,

, I i- I ~ iTHE SCHEDULE ( see Rule 18(i)

RETURN OF i.SSETS & LIABILITIES ON FIRST APPOINTMENT/AS ON p

1. 1'- .~ne of the Government Servant in full

(I' block letters)

2. Sf IV1C'..m which belongs

3. ') 'I;a! length of service up to date

i) in Non-Gazetted rank

ii) id Gazetted rank ------

4. Prese i t post held and place of posting:

5. Tota mnual income from all source during the calendar year Immediateiy proceeding the 1stJanuary,2011

6. DECLARATION:

1

-Ihel ;'_y declare that the return enclose namely, forms I to V are c;omplete, true and con-ect as on

to the h: ;:t o' my knowledge and belief, m respect of infonnation, due to furnIsHedby me under the provisions of sub-

rule (1) )erule 18 of the Central Civil Services (Conduct) Rules,] 964.

Date: SIGNATURE

Note: 1 This return shall contain particulars of all assets and liabilities of the Govt. Servant either in his own name or in the name

I)f any other person.2) If GOyt. servant is a member of Hindu Undivided Family with Copl;.fcellery . ights m the r'roperties of the family either as a

,.trta" or as a member, he should indicate in the return in Form No.1 the value of his sl'lfe in such property and where it

, not possible to indicate the exact value of such share, its ar,proximate value. I

--- .

. . I ':

"

FOR M NO.1

STATEMENT OF IMMOVABLE PROPERTY ON FIRST APPOINTMENT / AS ON

(eg. Lands, House, Shops, Other Buildingsetc.)

l.__

Date:SIGNATURE

r--- -- - - --- - - ---

SI. Description Precise Area of Nature Extent If not in Date of How acquired Value Particulars

Total -, RemaksI

No. of prvpery Location Land of land of own acquisition by purchase, of the of annual(Name of ( in case ( in'case interest name, mortgage, property sanction JIlcomeDist., of land of state 111 lease, ( see of fromDiv., & landed whose inheritance, note 2 prescribed theTaluk & building) property) name gift or other below) authority propertyVillage in held, wise & name

if anywh icll the and with details of Iproperty his/her

person/persons !Iis situated relation- from whomI

& also itsship, if acquireddistinctiveany, to ( address and

no. etc.) the connection ofGovt. the Govt.servant.

I servant, if any,

I with theperson/persons. I con.:erned)(pl.

Isee note 1

below). I- .

1 , 3 4 5 6 7 8.\ 9 10 11 12 13

...

I

_.- ._--

...

I

-i

-

f r I

, 'J J "1',

"I,'"iV.I ~..

.'

FORM -II

STATEMENT OF LIQUID ASSETS ON FIRST APPOINTMENT/AS ON THE

~ 1) Cash and Book balance exceeding 3 months emoluments.

I)) Deposit, loans advance and investments ( such as shares) securities, debenture, etc,

Date: SIGNATURE

Note: 1. In c(lunm 7, particulars regarding sanctions obtained or report made In respect of the various transaction may be given.

,2. The t~rms" emoluments" means the pay and allowance received by the Government Servant.

- -- - - ----- - ---..... --- ---- - - ---- - - - - --

S.No.

1 --

..

Description Name & Amount If not in own name, Annual income Remarks.Address of name & address of derived.

company, Bank, person in whose nameetc. held and his/her

relationship with the

Govt. Servant. ,.

2 3 4 5 6 7--.- .-...-..

II

- L

. . I

j

l ..:1

..' .1. .

i,

FORM-lII

STATEMENT ON MOVABLE PROPERTY ON FIRST APPOINTENT/AS ON THE

Description of item I Price or value of the timeof acquisition and/or the

total payments made up todate of return as the case

may be, in case of

Sl. No.

Date:

If not in own name,Name & address of

the person in whosename and his/her

relationship with theGoverrullentservant.

SIGNA TURE

Note: In ttns form information may be given regarding items like (a) Jewelry owned by him (total value), (b) silver and otherprecious n'ctals and precious stones owned by him not forming part of jewelry (total/value) ( c) (i) Motor Cars (ii) Scooters/Motorcycles (iii) Refrigerators/air-conditioners (ivO.radios/radiograms/television sets and any other article as the value of whichindividuall~'excess Rs.I ,000/-(d) value of items of movable property individually worth less than Rs.l ,000/- other than articles ofdaily use s,.1chas clothes, utensils, books, crockery, etc. added together as lumpsum .

Note 2. In ,'olumns 5, may be indicated whether the property was acquired by purchase inheritance, gift or otherwise

Note3. In column 6, particulars regarding sanction obtained or receipt made in respect of various transactions may be given.

--

- 1

How acquired with Remarks.

approximate date ofacquisition

--

J

r

:.t .1". , J ~

Ii

I'

I

FORM-IV

i ~

STATE!\.IENT OF PROVIDENT FUNDS AND LIFE INSURANCE POLICY ON FIRST APPOINTMENT/AS ONm Insurance Policies I'

SI. No. I Poh..:

No.&Date (

Polic

~I

II

Date:

.

1

SIGNA TURE

,Name of Sum Amount I Typeof ProvidentInsurance insured/Date of annual Fund/GPF/CPF/Acco

f Company of maturity premmm No.

.

,

3 4 5 6--._--

'-

Provident Fund

Closing Contributions Remarksbalance as made ( if therelat suhsequently. IS inputreported regarding .by the closingAudit

, balance

I /Accounts

theOfficer figures

I along withaccording

date of to the

I suchGovt.

balance servantI

shouldII also beI

J

mentionedIn the

column. --,

7 __ 8 9 10I

--i-. _.-

j

II

. .,1 .~

.. I. r

FORM NO.V

S [ATEMENT OF DEBTS AND LIABILITIES OF FIRST APPOINTMENT/ AS ON

Sl.No.

II

II

i1

l

Date:

u

'!.

SIGNATURE

Note: (1) InrJVidualitems ofloan amount exceeding three months emoluments of R~;.I,OOO/-whichever is less, need not be included

(2) In (()iumn 3, information according, permission, if any, obtained from or repori made to the competent authority may also begIven.

(3) Tht term 'emoluments' means pay and allowances received by the Government Servant..(4) Th!' statement should also include various loans and allowances available 10Government servant like advance for purchase

of conveyance, House Building Advance, etc. ( other than advance of pay al!ulraveling allowance) advance from thea.p. 7undand loans on Life Insurance Policies and fixed deposits.

(

L

I

Amount Name & Address of Creditor Date of inc

liabilit..

2 3 4.

-

mng DetaiLs of Remarks.

transaction

5 6-- ..

.--