DR~ MARRI CHANNA REDDY HUM~ RESOURCE DEVELOPl\1ENT INSTITUTE OF ANDHRA PRADESH

Road No. 25, ,JubUee Hllls.Hyderabad, SOD H,9

fqq <rnIIICfil/DESCRlPTnrx ROLL

_ ..... ' .. ,.ai.. LJ_ _ KWW4-0440-W;LW44A4

~,~.lL3n, ~ ~/RANK IN UPSG

(Ple::t;~e paste one

BL,ck ,f;; \\lute pIl!otOgntld.llif'l'lE' and atttach. 1. 0 extril!:

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latestphotJfJ graphs with your nam..e wriUen 0 n the back side vrith this fonn)

2.

3. tm <rm ~!SER.VICE &. GIillRE.: OO/SERVICE. ~/CADRE

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(~ :w~ ,~~..! ,~llfR ~~ ;- !: ~I ~~ 5]J1 §!iJ .. I AUOTED ro YOU. IF' NOT ALWTIED PlEASE 'WRITE M.A.)

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~1t/NAME : ]"~*il .w:rI:.:.:::R-;:;;.,sr~·~ """.,..... ........... '- .................... __ -..;~~/MIDDLE _

5. ~If mtl/DATE OF' BI RTH :

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lI1IT-II 1M o NT!{ I

cPt/YEAR

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6. ~ IR.ELIGION :

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EDUCATIONAL DETAILS (In. CbrOlf).olo£ical order b,cginning.from High Scbool onw,anb)

1.

2.

J.

4.

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ACADEMIC' DISTINCTION'S OB!AlNED DURING YOUR EDUCATIONAL q:f..REEI\.:

1.3. ~1 Vcfiaif iffi fcrqri:if/DETAILS OF PREVIOUS JOBS HELD

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1.

w''lf;IPuiod To

Y:-"~"'II¥¥

p.IP~riod F,om

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2,.

4.

5.

],4. ~;~f&1~ ~~-Cffi~ 1fij 'fq~~/ ~!!.~~ ~1~~1'lff ~ ~.,., ~, ~~ zt~ DETAILS OF NQN·~~Q.EM.lr;:: 'PJlB~l,JITyDISTINCTION IN THE 'FIELD or SPORTS I EnRA-CURR~GULAR ACTIVITIES:

16, rym I'm:[,i..! !!. ~~C1: (ll"R ~ ~ ! ~ ~ ~ ~ ~ ~ llf 'il1f~~ ~ f;/ilcn1ffil ~

~ ! ~ ~ ~ ~~ ~ ~ fr!li~C;lJARDIAN'S PROFESSION (If in,

service. indicate service" If dead or retired. the profession before death or re~ir~IF.~nt) : _

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17. 1;ffiT I.AD DRESS: :

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~'reT PEKMAJiENr,AJ)DRESS

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POSL.ALADDRESS

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NEAAE3T FAX AND r£LEPR«VE

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Clolony/M+~hallalStrel!t

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1lffi1:! City

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"U~I State

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ftR' a;4l~ /PIN CODE

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FAX NO.

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mq:;)~/pIN CODE

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18. ~ ~~/Er.!!:'1! Of DOMICILE: r~~!1 DISTRICT:, _

19. m~:!l :!ltzrq: ~ ~ "I:R)/MEDIUM OF INSTRUCT~ON (ATSCHOOLlEVlEL): ~

20. ~~:Wn 'wm tr' c1i:fifr.f'l(.fi ~~z.rl OPTIONAL SUBJECTS AT THE CIVIL SERVICES

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EXAlvUNA nON ~

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a) Pre.limina.ry,~

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21.m~' ''qTI m~1 MEDIUM OF IN5TRUCT'ION :

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~~ mau ~ 2/Pre.univ,ersity Education fcf~fqm~~ rn&lll Univer.sity Education

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UPSC VIVA· VOCE/INTERVIEW: ~~~~~ __

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24·m ~5.:1l ~ :IL~ .~. m~ ~}!f!.i.~ ~ ]~~~I MEDIUM OF tN,STRUC1l0N

PREFERRED AT THE-ACADEMY : ~~ ............ ~_

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2. ~l English

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~/HEIGHT :

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27.

q<ifl/ WEIGHT:

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28. Qil:T"'( trV BLOOD GROUP :

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(W!ey 5EGNAtuRE )

(3f~~%11' ~ 1Tli )

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(NAME OF THEC.ANDIDATE)

m:Qm/DATE _

iltffl'~9 -e, t ~·2.8 ~. ~ .~!1! .!!!!. ~! !!.!! 'Ji~ ~ fu~ m ~ !£ ~"ftiJ¥lj~'h~~ Mdl'(F~lcfil irf-rtnfu ~l 1f{~-Q;, !a'~~lr 1Cftrali ~ nJ ~ ~ mer'l}~i CJRI ft ~ q1- W

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(~. Nos. 1 to 28 ere. to he fined either by typing or handwritten in neat capital letters usini: bleck ink Please paste one' Slack & White photo graphand attach iO extra latestpnoto gr:a12hs with your asrne written on the back side with this form The phote grsphs should be Black and 'White of good-quality with a light shaded background)

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Cfi"'1l1J ~ I ROOM NO.

iii)

~ ~ mIl COUNSELLOR GROUP NO.

DR.. MARRI CHANNA REDDY HUMANRESOURC£,'DEVELOPMENT INST1'flJTE Of ANDHRA PRA.DESH

Hyderabad

4 tITl(u[I ctmn/(b~dl ~. f$" 3iqqil\lIlfp.11' R~lttCt tg ~ ~¥flN1 T[fq f'1"'ij~11re' t- .

I Declare tha,t my 'Home-Town' for purpose of Leave 'llilvd 'Cmce:sSiOfl is:

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--~~------------~----~------

Name of TownlVinagCl_~_~~ __ ,,",",:-_~ ~_~~

~1{/S~re _

~/Ftace:

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a-1~IG/Dated:

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'·cti.h!OI' ~. ~ ~1r ~ lffil1~fi«n. _1irl/~ ~ .~. ~ '~' -qcj ~ ~~. q;r ~lf4(ji!jjq,~~IRI

'Reasons sue;" as Permanent feSldence ofnen relatives like pareats, brothers EtC property etc

~41?i'I· AC CE PTED

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lha.'t I am. urunani~i.d'owerlwidow.

(jj) ftn ~ ~,cn1td ~ ~ ~ ~ \'Q) ~f~d ~ t.11 That I am married and have only ooe wife Ii.vi.og.

(iii) ~ ·~·ftr_ ~.~ J;rfr tr<P ~ ·~vnftla q1f1£1i .~ I iIE'QGA ~ ~--.:lF.{ ~ i~ t I

That I am 'nl.!ni.ed Zld have more than one wife living Application for gr.ant of exemption is enclosed.

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If{) ~ IQQIIe.ti ~ ¢l!"I..jof"'t'1 '-11('1/ "'I'r'"11 q'l'lJ'lIQ""'1""lC1 ..., ~., '1,,'t1'(1 Iqql~ rr.n\.,j,1

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11lac 11m married and that during. tbe life time of my spouse J have eontracred

another marriage, Application for grant of,ex.tmIption is enclosed .

(v)

ft ~ Fcrqllim. 11 3!1~ vnn (fq) ~ .trn1 to tR· ~ .. qft ~ ~unfqo

tWfl o:r6tt: I .

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knowledge.

(vi), fm ff ~ dlfiffi t ~~ :~~h1 ~ \in xtft ~,:Rn'ti$i ~. ~. ~ !Jl ~ ~. ~qi vfti1ta' ~··i .g II .~ ~ ~ ·1lltPn--~· ~'Irr ~ I

That Jhave contacted a lTUI.rriagevnlh a person who bas already one we or more living, )\pplicatioo for grant of exemption is enclosed.

2 it '(ifQP1tO! ~ Qra~r qmn/~ ~ t% ';;'l4g«f m1l;OIl m=q t ~ ~ ~ 14~ t=I~'~m/~mft li ~ '~~~fire -ij)' ~ ~ '4~~U~1 ~. ~ ~~t?t~. IN 1jlr '~ ;9 iHlll.ffi fcpm 'iJfT ~T* I

[solemnly affirm that. the above ded.aralioo is true. and Lunderstand that Ul the event of the dedara.tioo. being found to be incorrect after my appointment, I shall beliable to, be ool'!Jl.is~oo from service.

e

~/Date

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~'=rC' ~5 ~ ~~ ·(1) ~~ q ~. :.i; 10 fr;. "9 i: ~~ 4>1:: i: I Please delete the clauses nQt apphcable

DECLARA"TION

WHEREAS the provWon of Rule lJ .. A of the.AlI India. SeJ:victe, lConductJ Rules. 1968/Rule 13·A of dle Cel:!.tnil Civil Services rConduC't,l Rules. 1964 han:: bc!1!fi :6P~ brouglu to my notice;

NOW there fore , I, ShrilMs.~~~~_~~ -.._~~ ~~~~~~

(NEimel

___ --------....------~~ Probatio.nc:r. do hereb)' Wldert:a.ke that ]' shall aot:~

tal give or cake or abet thlC' gi:ving or 'taking of dowry. or

I[bl demand, dirtcUyor .indir.:ct1y trn'llr! the parente 01)" guard.ian.s o.fthe bride cr bridegroom. as the ease .may be, BDY dowry.

,[ afii."!i my signature :t:o ll:W; declaration in the fullUllci.enl!:3ndins thM fMJ,y brcElm of the rules or la .... • re lating to dowr.y I"iIbalJi render roe liable to .appropri.ate aetitlll:

Copy to:

R.wle II-A of the All 1 III diG: Semeeli iCon~t) R1des" 1968,

- ~ - b _. - "-" , - - .

1 J~A Giving or taJ."inf;J ,oJ dowry· No' m.ember' of the &n;~ .-:1iaCl .

fii·1 demand, cli:-ectly 'or in.dircc'tly. &o.mthc F&'@t:tI cr l,uardLi.an ofi}, uriu!:': 0" bridegreem, ,Ra the (:"USe l:na:y be, any doWry.

~1:m:O.l!ru!; Forth,e purpc~ of trus. rule. '"fkiwry" has the 38m.!!:: 'mea.nJ:ng I!UI. In the Dowry Proruhiticn Act 196! ~28 or 19611

IIi: lif.ma'1·rj cirecrry 01' HL.MU-U!Jy. lrc:n Ihl" r;ur:r,1 0: !!",.J.ard);,lJl~ .. .! ;"'! '.'nri-.: I1r :-,rldl"B"':-W;'; .1" ihe case rn "'-y be, ,my c.hw,rfY

I; .. KT·~'~~~:::-~.!)f~~ ~._-;,! 'f'h~ : .1!'rns·r~ p~ f"[ •. !:a.. F\~~C". d~"",~T";" h.;:--.:; !"nr'" q~!m r "1!.j':~l~~;"':';:.r ~'!j~ ,~., t·--~r- r J(I .. ..t-l~'·

r~r·:-.-a.~JJ1~~uJr~ ~ ... ~r ~="~. t 1.s ::.: ~~lJl~

~ ,~'~ '~li '\91;n' (3fTlffU1) f1q;l!I2I~n, I%S-'ti} f.!mj~ 1'1 '"\! d~1 q'h~ru ftiltl.r. frm (~crr) ~il''ff~. 1964 ~ ~ lJ--x ~ "TO '~ ~ 'T1;~'qfI) (ji \3tla~"1$l ~ '~ ~ \ifA"ijilfj 'cfi 1Ji i:

3fR' -q ~ ~ ~ ifaiI"qcu@d ~~t1fc1iq fj, __

~~,~_ ~_ (qftftIHI~'1 <m ~) ~~~~~ __ ~ (;frqJ Q'il. ~), ~ffitfR t>:dif\~RI zr&; mFf ~ffi/~ t. fqi li ~

(Cfi) '~~ ~/{m, ~' ~ ct-rnAi1fl anx ~ wr ~ ~

<l1 tii~ 1/ lift, ~ J~. ~

{~) ~i ~,~ 'R ~ 1ft IDll m) cti IfJOT-t1«n rn ~ -~ ~el a;r~ ~&1 ~"~ 1r ~ '"*' '11fl1 ~' (fiwn/~ I

ft'tqUft; w"'duf" ~ ,q#t ;;m/ .:vfiht(f t un ~ ,mFrWEl ~. 19M (196/ (fiJ 18) ii" ~ "((lf1' ~I

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J1 fuM 1lN ~2J 'inn (31nih!V1) ~ Q"'Ill1,~ • 1968 qij' ~ U';'Q' (Q1)~~01 ~I 31~ #'11 - '~ trn1 Qil cmt "iff ~

(1) ~' ~.~, ~' ~ '#iTff ~ ~' Gl' ~\ii ,a~ :al ~r~ m f~~ ~~ ~:;

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To

The: P:rcsid..cnl of lnd.ia,

'W:he:f'!e8B i. 0 c.andi4a,te (herema.fterre1erred to -:as 'th,'e

trainc'C'1 re<:Ommended by the Union Public Service Com.miss1on .for appomtment to tn.!! Indian Police Sexvicela Central! Service, Cl.as.; I Service. on the results of Civil Services Examinatkrn, 20 'beingentitloo to receive from the President (hereinafter referred to as the Central Government) pay and ,aJ1owanca du.ring 'the period in whieh I ,am, undutrainingat. the Lal B.a.hadur S.h.m.!1:ri National Academy 01 Ad m.iniatra tiO:r:li , Mu,a:sooric. Unranch.a1lherdnN"ter rdel'ud to as "tne Academy"J

An whereas the trainee is required tofUmish Surely a~ herein contained.. And Whereas ,at

the request of 'me trainee and in oons.idero'l.ion ,of the premises {name)

t~t,~

_____________ fieSI.Wi.lJi.£ at ..

Ibueinafter :referred to as Sur,ety,1 halle agreed to st.a:lld ,M SUl'e'~ for thctta:inee as herem conl:.a.J1Dcd. Now. wei tbe trainee, amd the surety jointly and :Be'Veraliy, do ben::b!y. prnIr'-i:se and agree lb,a..t in the eveat of the failw-,e of tbe trainee to complete ,his '17ain.in,g at tb~ A<eademy to till! sati~tion of the Central Governmmt to refu.c.d to the Central Goy'cmm.ent on demand wlitb.out demur any moneys paid. to him, including pay ,and .tmvellin,g e:xpen~s. And.it is agn:edthBtthe decision 'of th(: centI-aI Qovc:rn.m.ent as to the f.ailure or the trainee as aforesaid, and the amount payable by the tresnee and ~urety .s.haJ1 be final and bind.ing on the traineeand Sure~.

The ;surety hereby 6i.gtCtC:~ that hb/hu liability bcn:un..der shaU Dot. be: ,a.I1e(:loQ m'I aeeeunt of the Cen~raJ Government giving the Tra.inee ext'ensi~n 'of time far paym,ent "of or almpounding the amount payable hereunder Dr on acceua: of any indulgence shewn to ~Ehc trainee.

Date this ~~~~~~ day 01 --- _

Signature of Tntin.ce

"

Si&:o,edby the Tramee in the. presence of

Occupation

Name or WitneSs

Address

Occupation

whose, signarure is appended to the

above agreement a.s siarety, do hereby declare: that I am

c

(n) l~1 i.hiC' permanent service of the Oovernment ef

or

,:b,1 Ordi:-:'''''lrily re aident in India arid that I possess ml;.ClrVi which ""-ill ennhk rn r- !(j

repay 10 [he Centra! GO"ie[-n.,r:Il.ent the sums 'Or moneyreferred to, w the: event of my being c.ajJt~d uponto do, so iaaccerdaccewith the terms of we agreement,

Slv\a~ure QL surety

Signed by thesurety in the presence ,or

Address

~ < (" qllfl i}'ithrrfr &' Rl >I~·P.::r ~ q;- l-f:.! 1 vrr-l < rr..-'Il \~ 1 r!

FORA) TO lito: '-ILum BY GO\. ER:"JMENT [,\lrLoYEE:S ON FIRST ;\PPOINTI\lEN1'

r f~~zrt f~- f.'i;n-ir ~ -~~ 1;1 f<f~~h I

I, ~ I!>;\ 17f11-I-Ill{1 r.r'f.'! ~i<1,11 (]\)~C relations who are Nationals of

I __ ,q ;o~· ~omiCir~ in other ~O\lnl nes -I-

I" __ ~ ~~/Fathcr J,

III 1 lfRlT/Mothor -1

I-I;~_ r ~/rrft'f Wifu! HI;~b~lJ1d __ -< __

I 1\ i Tf/Sons [s]

._, - - - - -, - - -.- -------

I' g-::ft/gf--P.'1 Daughter (5.)

- - ~--~~~~-~- . --

VI "irtlBrothoc (s)

21 'lffif .\ f-Iorn <., ~ f-I"'" ---:: 'll"

NIlI1OC1

. - - ,--- ... _--

: If Mother j

~_+:\-9V '1m Wife: -Hu~-~-~I-;~ ~ _

IV ~ :FVSon (s) _

'1_ 'I_--i- ~/ ~_~lli D:.uBhte~t~~ '_J_- --,-----'

II _·qrV BrOIII(l~ t~) _ , I

: "-II L ~/orl~.'i Si~tcr (s)

Name

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<'RflWl qui Present Address

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

-, . r

~"t@ Nationality

<R'fTfl1 V{f1 PtCSCf1t Address

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___ l

\JI~ ~ll, Place of Birth

--~

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Place of Birth

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.C.tio,Hi r~:

OCCllp;lllon

OCCUp.1t\(Hl

,I", -Fh'll:"','/"TU

- .

I

-;

11f<': Tl\'<15rt'l ~ ii t:'i cjl ~/ CfiTURor<:! "ifil "flli-' (~ ~ ~) ?It:/l 'Q<:, ~ ~ <nl ~ fW-Rvl -e 3l'r'l': ~ lj 2.rr-i ,M ~. ~ I i\ ~ <Ji«fT/~ t 1% ~ mfi ~ ~T,f! -llR ~ t.q;rr<ffi ~ ~.afR ~ tl

tf In publ ic service. gi Vii) full particula rs rQg.'\rding designation of the pOS': hel d name of dep a rtrnent/off co etc. where employed and the date of suchemp loymOll1 I certify that the foregoing infonnllrion is correct and complete to the best. of my knowledge lind belief.

~/Signntllre.

~/Design3tion _

~/ N.xe: I. ~.\lQ"':{ il <fI vtR ~ ~ ilil fn'qn:n .>J'I"FIT ~ ~ wrnT V'\"1lP1l.~ ~ ~ ~ iili!:itiJl'RI fclrit ~ i:fi'l'l <bl ~~

~ iJi1 'Wfjffi ~ '- '-

Suppression of infonnatioa in dus. will btl oonsidered l' major dq>ll~eotal offence for which the pl.ll1i&hment may extend to dismissal from service.

2. \3"tlf<R1 ~ q'; ~ ~ iliTIf q1~~ nm t (h ~ ~ ~rn&:I:~1' <PfllfFroraUH q;'\ ~ <'Pf <i'; 3ict it i!!

Subsequeotchanges, if any, in the above date should be reported to the Head OfficefDepartment IJt the endof each year

!;l~ ~fittt ~ ifTlRI lRf ~ "lIT"Rl ~ ~ m fWft ITf i:fll Qll'ti STATEMIi:NT OP .... 'O'i.A.11 LE PItOPI~llT"" ON FIRST AI'POI;-.(fMENT

q1fjYEAR

I.

~ 'q,l ~ ~. am :ff<I1 ~ qg ~Iira' ~ ~~.

Name of the Offi eel" (in full) and s~rvic:c to which th~ officer- belongs

crd'JlA qc:/p(esent Post

J. trdln'.; t-ct"f/Present Pay _

2.

;,n;! ~ ... 1 ~1~ ('1m ·lRi'llOf "It'-tl--r-71-C:~:-~-:-~--q'{-4~f i'-ffi--r--:c(;{--:':-3f-:ftl::-C\Jfc:-Cf-~"-l- ~ t. iirmm it ~.

~ Present Value ~ flRr.f; 11''1 ,~~ t (l2(r \31l6H q fl'lct'l zn ~ (ffi) ~ 'QNl' s~ t:

NDmO and delaIll or Movnble \RI<f>l <!>1l"l~ <iI l~ ~ 3J!vio '<f'~ <P'I ~ ~ <;l1l[T 'T'-l &J~m

Proporty If 1\01 in own Nl\.i~ staL6 1t! If>T '9'tTT \f~ ~<RUI ~ fGr.ro ~~ ;$\ t

whO$$ narno held :lIld hitlher How acquired whether by purcbnse, inheril1lru:e.

n:lal[onmip 10 I he CI.IVt. . n I . . th da

J Servant- 'V or ot lCrwIS'\ ..... 1 te ofacqui5,iliOOMd

name with detall& of persors from w 111;)U1

------,-,------ -i---=c----+-- ----:-:-:-----'-+'~'--. ----...,.",-

(I) (2) (3) (4)

~--~-.

:wgr.ffi'm Pem:lrks

i

j

--'------ ------

------- --------- - --_. - - .-

~ffieR/ Sigu01IUre __

~;;flqj/DlUtd: _

~/Note:

~JUlqr/'lfJ.g.trCfr. ~ j;j~ ~m fGtU~ ..s:rtll) t1tf1 <i: .j;j~ ~ q,~-i[{{ c:frqvjl lfi14 11 Sq~ \Hf ~) ~i51 liL-ffiTl :Iil ~'W'I ;:--n 6''R' I .~ iii ~ \Rfiii 3JeR <m=I ~ m 'lIT 'llRq,~ <6 F<n{~ TR ~ <$ ~l lIT 3fi.1CIl fb;~ ~ c!:ff<m q'j'"'ITl'I 'IR I

1110 declaration form is required (0 be fHled in and subr-iirted by every member of IASflPS anel ChlS .s I and C:ass n SM vrce , '!'<'''r13 p.HI,..:ula,." .y-' :111 movable property hel d by him eitnor in hi. own nama or in the 110l11e of :)nY member onus famil y or in the name or allY othr:, p""u,;,;

• ~. m)·-'Tnfl 1'J.(;rI !~~l ~ ~ 15), cll$i WFI ~~ m ~'I:r.flH ;j;'"Tlll~ti 't~ <.~~ I

In cases where it is nOT possrble 10 )I~St!55 the value ;.ecumrdy. tim arpH))ornalc Y:lluo in relation to present condinons 11"':0-' be 1I1c!,.",In!

~I ANNEXURE ·11

1l~ P1gfiffi "$ ~ 'If'U urr.~ mm 3I'WR ~ q') ~ zrn 11'fI"1f STATEMENT OF IMMOVADL!~ PROPERTY ON FIRST APf'01NrMENT

'lf6f/YEAR _ __ ~

I.

~ (f1J Wi "'IT'! ('fl!.fj -flCfl ftltffl triO ~ t ~ " _

NNne ofthe OffiCCT (in full) and service to which tho .offictrbeloDg3, . .. _ ..... __ .. ,. __

~. ttG:'/J>r-esentPo~, _

2.

: Rri~-:- ~q{p:.j. ~ lfq~ CIil -:~-;-n. ~

i \T1I TJt<t "ifil "lfI'I ~ Name IIIld dWils cf'Property ~~fr

• ~ ~l·~ ;wR 1JlI' ~ "'''i3!~'' "'- ~. ~ Present Va1m II'{ '"'!iI' ~ ffJ ~;' ~ .... ~ vfr. ~-ro'I. ~

~. ~ ";:[1"l:[ ~ flImnf it ftR;fr, ~- Annual t ~ ~ ~ N 1tT .aA' ms ftom ~$ 'miT mG'I §t I ~ m ~ Property ·m IIn.ot in OWII "t'trtR!'1! ~n ~ ~.~

'name; .~ In ~ "IJll' ~ ~ltl{llf ~ ~ ~

n_ hald l1li11 .b.b.'ber liTt:n' lilt' fr Haw _,1-.4

rcledcmdtlp to tbo --"'i--

Oovt. SGmlnt wbetIm by p~ !c:l\lllCl •• D>l,'Irtp&O. .Irbatcmal J;ItI: Of othctv.Uc, .,nih data or

I k'qubition IIld ~. wIIh

I ddalls DC ·PCrsoD;l fi-Dm ""bam

L ~-----_+-~---- ~I~

_2_ _ __ ---"-- __ ----'--. _ . __ 4_.____ 6 1

.---~.- .

~ ~1'i1 ;W~

;mJl REMARKS

lncorne

lh.!

:-.lllIrlt of Districl. Sub-

Diviskm, TBlukand

Village III wwth

propert)' is situ.tcd

1f!f;FI-q:<i

3RI 'IfII"I Housing and otbn buUding

- ... _---

g

.... _--' - -_._._.-------------

l'".!rrr<'i/Datcd: ._

-2-

~ Tfffif1r~ ~ ~(3ffq'<tI]) f.1lfl'lcr~ 19M; <$ f.r{[~ 16(5) ttl 3id1f(i 'lfIJt~/11T.~.Wcf/ ijj \n'ijq; {r~ftl q;'r 3fR cj'··~1 ,,; f~F:d ,'HI (3lTifirU() f!I"Q-qr~. 1,965 <f; ~ L8(3) -m 3t~pld 1I'l1'{ rr~ fG"tft7i ~ "$ "f\c:rfti'l em jffl ~I ~ is; f.'Ml, ;Y1~~rh: -A) ;.~ ,·q"ffiln "9 ~clI, q¢ q~ ~ TTt m -hfiP ~ --rr~ ~ 'fiq~~ Qii '~ m~ (f15' \3"ifI~ ;wA' ~ "!R m- 'lJIqft"QR ,t I;}i,~i) ,;-I;r fr~ * 'lflI q'(" 3j~ filRfI JRl a.rtiffi if; "Iflf l{~ m- ~q., ~fqq $ ffI1lI 'l{{(fi"""{ ~ G'1{91 l1rrl1 '~ .atR iCft:;" :ij ~."j ·HI'(III <1;1 -;[rRT ~ 12 ~ .~ a[tHT('i "" ~ ;JJr.fr tm1l t 1

Note:

-

The declaration form is required to be filled in IWd submitted by I:lvay member of lAS/IPS under ruk:: 16(5) ofthe All Indin 5,:tvic1:s

(Conduct) Rules 196& and Class I and Class Il Service UDder Rule 1:8(3) of the Central Civil Service (Conduct) Rules, 1965. on first r-ppoin trnent to the service and thereafter at an interval of every twelve months, 19'o'ing particulars of all immovsble property owned, acquired I1r m1lerrlc-d hy him or held by him all lease or mmtgagll"f,ither in hh: own name 0: inthe name of any member or his family or in the name of any other pt:!S(}II~

iJfili. fl"tfr-~~ 'i~ ~~1\-l1l·q' '",g), crt$'1 C[~ ft~tl $ 3fj-H1'! 3fj"S-JrPrct "'ii:'ll ·~~M I

Incases where it is not possible to assess me value accunuaty, tho approximate value in relation to present ccnditions may k "ldIC1C..:(i

• • VI) ~ '1 fll. (blC if I Inapplicable c lause to be Su;u.ck 0\[11.

o

......

3'l<?'"11 q R ~ ~ '4'r fIiA:Iftrn ~ ! Includes short term 16IlSe also.

FORM No. II

Statement of liquid assets on first appointment as on the 3rt December 20 .....

(Il Cash and Bank balance exceeding 3 months' emoluments.

(2) Deposits, loans advances and investments (such as shares,securities, debentures, etc.)

SLNo. Description Name and Amount Ifnot in own name. name Annual Income remarks
address of and address of person in derived
Company. Bank, whose name held and
etc. his/her relationship with the
Government servant
1 2 3 4 5 6 1
"
J Date: , .

Signature .

Name ..

. (IN BLOCK LETTERS)

Service .

NOTE 1. NOTE 2.

In Column 7, particulars regarding sanctions obtained or report made in respect of the various transactions may be given. The term, "emoluments" means the pay and allowances received by the Government servant.

FORM NO. v

Statement of Debts and Other Liabilities on First Appointment as on the 3pt December 20 ......

Sl.No. Amount Name and address of Creditor Date of incurring Details of Transaction Remarks
Liability
1 2 3 4 5 6
\ Date: ..

Signature .

NAME ..

(IN BLOCK L£'ITERSJ

Service ..

NOTE 1. NOTE 2. NOTE 3. NOTE 4.

Individual items of loans not exceeding three months emoluments or Rs.l ,000 whichever is less, need not be included.

In Column 6, information regarding permission, if any, obtained from or report made to the competent authority may also be given. The term "emoluments" means pay and allowances received by the Government servant.

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 allowance, advances from the GP Fund and loans on Life Insurance Policies and fixed deposits).

.

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