Form A (See Rule 2) Statement of assets and liabilities filed by .............................................................................................................. ......................................................................................................................................(name and designation of the public servant) for the period .............................................................. to ................................................................. 1. Name : 2. Permanent address with Telephone No., if any : 3. Name of the members of the family and his relationship : 4. Present monthly income : 5. Liabilities (a) Nature extent and other : particulars of liability and the date when it was incurred (b) Nature and address of the : person to whom the public servant is liable I, ....................................................................................... do solemnly declare that the information furnished above is true and that nothing has been ommitted therefrom. Signature of the Public Man 6
