œ¸€¸ÁŸ¸Ä - ‡ FORM – A

‚¢š¸ˆÅ¸£ú ׸£¸ ¸¥¸-‚¸¥¸ ¬¸¿œ¸¢î¸ ‰¸£ú™›¸½/¤¸½¸›¸½ œ¸£ œÏ¬÷¸º÷¸ ¢ˆÅ¡¸¸ !¸¸›¸½¨¸¸¥¸¸ œ¸€¸ÁŸ¸Ä
Form to be submitted by officers in case of purchase/sale of Immovable/Movable properties.

ªú/¬¸ºªú/ªúŸ¸÷¸ú Mr./Miss/Mrs.________________________ˆÅŸ¸Ä¸¸£ú ˆ»Å’ ¬¸¿.Staff Code No.________

©¸¸‰¸¸/ˆÅ¸¡¸¸Ä¥¸¡¸ Branch/Office__________________ ‚¿¸¥¸ Zone __________
œ¸™›¸¸Ÿ¸ Designation _____________ ¨¸½÷¸›¸ ¬¸¿¨¸Š¸Ä Scale of Pay __________
Ÿ¸»¥¸ ¨¸½÷¸›¸ Basic Pay Rs. __________ ¬¸ˆÅ¥¸ ¨¸½÷¸›¸ Gross salary Rs.__________
í¸˜¸ Ÿ¸½¿ ‚¸›¸½¨¸¸¥¸¸ ¨¸½÷¸›¸Ÿ¸¸›¸ Take Home salary Rs.____________.

‰¸£ú™ú/¤¸½¸ú Š¸ƒÄ ¨¸¬÷¸º/ž¸»¢Ÿ¸/ž¸¨¸›¸ ¬¸¿œ¸¢î¸/œÏ¢÷¸ž¸»¢÷¸ ˆÅ¸ ¢¨¸¨¸£µ¸

Description of the Article- Land/Building/Security purchased/sold

‰¸£ú™›¸½/¤¸½¸›¸½ ˆÅú ÷¸¸£ú‰¸ Date of Purchase/Sale

‰¸£ú™ú/¤¸½¸ú Š¸ƒÄ ¬¸¿œ¸¢î¸ ˆÅú ˆÅúŸ¸÷¸ (¢¤¸¥¸ ˆÅú Ž¸¡¸¸œÏ¢÷¸ ¬¸¿¥¸Š›¸ ˆÅ£½¿)
Cost Price/Sale price (enclose Xerox copy of invoice)

¬¸¿œ¸¢î¸ ¤¸½¸›¸½ ˆÅú ¢¬˜¸¢÷¸ Ÿ¸½¿ ˆ¼Åœ¸¡¸¸ ¥¸¸Š¸÷¸ Ÿ¸»¥¡¸ ˆÅ¸ „¥¥¸½‰¸ ˆÅ£½¿
In the case of sale please indicate the cost price

¢ˆÅ¬¸¬¸½ ‰¸£ú™ú/¢ˆÅ¬¸½ ¤¸½¸ú Š¸ƒÄ(œ¸»£¸ ”¸ˆÅ œ¸÷¸¸ ¢¥¸‰¸½¿)

From/to/whom purchased/sold (furnish full postal details)

Æ¡¸¸ ™¥¸¸¥¸ ˆ½Å !¸¢£‡ ¬¸¸¾™¸ íº‚¸, ¡¸¢™ í¸Â, ÷¸¸½ „¬¸ˆÅ¸ ›¸¸Ÿ¸ ¨¸ œ¸÷¸¸ ¢¥¸‰¸½¿
Whether through broker
If yes, Name and Address of the Broker

™¥¸¸¥¸ú ˆÅú £¸¢©¸ Brokerage paid Rs.

Æ¡¸¸ ‚¢š¸ˆÅ¸£ú ˆÅú ǽÅ÷¸¸/¢¨¸Ç½Å÷¸¸ ˆ½Å ¬¸¸˜¸ ˆÅ¸½ƒÄ ‚¢š¸ˆÅ¸¢£ˆÅ ¥¸½›¸-™½›¸ í¸½÷¸ú í¾?
¡¸¢™ í¸Â, ÷¸¸½ „¬¸ˆÅ¸ ¢¨¸¨¸£µ¸ ™½¿—
Whether the officer has any official dealings with the
seller/Buyer? If yes, nature thereof
‰¸£ú™ú ˆÅú ¢¬˜¸¢÷¸ Ÿ¸½¿ ‚¸¡¸ ˆ½Å 踸½÷¸ ˆÅ¸ „¥¥¸½‰¸ ˆÅ£½¿
(ˆ¼Åœ¸¡¸¸ ¬¸¿¤¸¿¢š¸÷¸ ™¬÷¸¸¨¸½!¸¸½¿ ˆ½Å ¬¸¸˜¸ œ¸»£¸ ¢¨¸¨¸£µ¸ ™½¿)
Sources of funds in case of Purchase
(Please furnish full details with supporting documents)

¡¸¢™ ¬¸¿œ¸¢î¸ ¤¸½¸ú Š¸ƒÄ í¾ ÷¸¸½ œÏ¸œ÷¸ š¸›¸ ˆÅ¸ ˆÅí¸¿ „œ¸¡¸¸½Š¸ ¢ˆÅ¡¸¸ Š¸¡¸¸
Deployment of funds in case of sale

Ÿ¸ÿ ‡÷¸™Ã׸£¸ ‹¸¸½«¸µ¸¸ ˆÅ£÷¸¸/ˆÅ£÷¸ú í»Â ¢ˆÅ ¢™¡¸¸ Š¸¡¸¸ ¢¨¸¨¸£µ¸ ¬¸÷¡¸ í¾—
I hereby certify that the particulars furnished above are true.

¬˜¸¸›¸ Place :
¢™›¸¸¿ˆÅ Date : í¬÷¸¸®¸£/Signature

›¸¸½’: ¬¸¿œ¸¢î¸ ˆ½Å Ÿ¸»¥¡¸ œ¸£ ¢¨¸¸¸£ ¢ˆÅ‡ ¤¸Š¸¾£ ‚¢š¸ˆÅ¸£ú ˆÅ¸½ œÏ÷¡¸½ˆÅ ‚¸¥¸ ¬¸¿œ¸¢î¸ (immovable properties) ˆÅú ‰¸£ú™/¤¸½¸¸›¸
œ¸£ ¡¸í œ¸€¸Ÿ¸Ä œÏ¬÷¸º÷¸ ˆÅ£›¸¸ í¾ (¬¸¿™ž¸Ä- ‚¸›šÏ¸ ¤¸ÿˆÅ ‚¢š¸ˆÅ¸£ú ‚¸¸£µ¸ ‚¢š¸¢›¸¡¸Ÿ¸ ˆÅ¸ ‚¢š¸¢›¸¡¸Ÿ¸ 20(3) ™½‰¸½¿—)— ¸¥¸ ¬¸¿œ¸¢î¸
(movable properties) ˆ½Å ‰¸£ú™-¤¸½¸¸›¸ ˆÅú ¢¬˜¸¢÷¸ Ÿ¸½¿ ². 25,000 ¬¸½ ‚¢š¸ˆÅ Ÿ¸»¥¡¸ ˆÅú ¬¸¿œ¸¢î¸ œ¸£ ¡¸í œ¸€¸ÁŸ¸Ä œÏ¬÷¸º÷¸ ¢ˆÅ¡¸¸ !¸¸›¸¸
‚¢›¸¨¸¸¡¸Ä í¾ (¬¸¿™ž¸Ä- ‚¸›šÏ¸ ¤¸ÿˆÅ ‚¢š¸ˆÅ¸£ú ‚¸¸£µ¸ ‚¢š¸¢›¸¡¸Ÿ¸ ˆÅ¸ ‚¢š¸¢›¸¡¸Ÿ¸ 20(3) ™½‰¸½¿—)— ¤¸ÿˆÅ ¬¸½ †µ¸ ¥¸½ˆÅ£ ‰¸£ú™ ¢ˆÅ‡
!¸¸›¸½ ˆÅú ¢¬˜¸¢÷¸ Ÿ¸½¿ ž¸ú ¡¸í œ¸€¸Ÿ¸Ä !¸Ÿ¸¸ ¢ˆÅ¡¸¸ !¸¸›¸¸ ‚¢›¸¨¸¸¡¸Ä í¾—

This form should be submitted by officer in case of purchase/sale of immovable properties

irrespective of the price (Refer Regulation 20(3) of ABOE(Conduct) Regulations) and all
purchases/sales of movable assets in excess of Rs. 25000/- in each case(Refer Regulation 20(4)
of ABOE (Conduct) Regulations). Even when the properties/assets are purchased from out of
Bank loan, this form should be submitted.

Ref : HO Cir. No. 556/20/31 dated : 30/3/1991

¬¸¿™ž¸Ä : œÏ.ˆÅ¸. œ¸¢£œ¸°¸ ¬¸¿. 556/20/31 ¢™›¸¸¿ˆÅ : 30/3/1991