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General
—Éåͨ ¡—Éåͨ ººàºÉ
à Æ ÌÍ À¼úâŽÆ ÀèÎÂ
è ¿ Àò¨åÊÆ (A4* S,.T, & E.) 09/76
(Internet Version)
ЈŠ»¾Æ ·ÈÎ¾Î»ÜºÆ ÁÇáºÆ ·Èξκ¯Î¿ÜºÆ ÌÁ¿È¹Æ¹Õ¶Æ¶¾Æ
Declaration of Civil Status and Living Conditions
1. ¾Ä Äͺå/Äͺà•Æ/ïÄﾗÆ
̹»ÇÆ
¶ÈÝ° /̱¾ÆŒ./ ¶Èݺ¶È°
Name
Mr./Miss/Mrs.

2. ¡—Éåͨ ¼, —Éåͨ ¼, ¾ùºøÀò¨åÇ ïɾàÑ ïÍåà ¼úÌà¨Ìå¼ Ñ

Ìè› ¼? ¾æºïÍåºà ÃåÚÆåÉ ïÍåà ÌàÉå•ÀêÇæËÆå •Æ ïªåÌà ¼?
¶¸È»Ç¿Ç,¶ÈݺµºÇ¸Á¼Ç, ±´Æ´Ûν»Ç¯¹Æ‰ÇȷƶÈݹƹÁ¼Ç,
¶Èݺµâ½â ·É¯Æ¯¹Æ¹´Æ´Á¼Ç £¾Æ¾× ÁÇÀƯÆί¶Æ ×ελ
¥À·Æ¶Á¼Ç?
Whether single, married, legally separated, divorced or spouse
dead ?
3. ÃåÚÆåÉïªà/ ÌàÉå•ÀêÇæËÆåïªà ¾Ä
ÁÇÀƯÆί¶Æ ×劁 ̹»ÇÆ
Name of spouse
4. §ï‰ ÃåÚÆåÉ/ ÌàÉå•ÀêÇæËÆå Ç°ïÆà ï¼ÀåںàºÉ
ë ¨ ïÍåà Ç°ïÆà
¡¾êªÍ
ò Æ Èºà ÌâÌà»åɨ, ĸà¶Èƨ ïÍåà ¡åƺ¾Æ¨ Û¨øÆåɨà
¨Ç¾àï¾à ¼? ¾æºïÍåºà —ÊòåÄ Éæ´êÀ¨à ÈÂÆú ¼?
§+Ư¿Æ ÁÇÀƯÆί¶Æ×ε ­ÇÆ £¼±Ç+Ư¶Æ ¶Èε¯Æ¯¿¶Æ¶È¾Æ
£¾Æ ¾ × £¼± »Ç¯Æ ¯ ¶Æ ¶ È¾Æ £¾Æ ¾ × ·È»¶È±Æ ± ´Æ ´ Ûν»Ç¸
±Î¹Š¾Æ £¾Æ¾× ·ÈÞÁ¸¶Æ¶È¾Æ ¹µÈ¯Æ¯ºÇƶƶ¹Æ¹´ÆտƿǼÇ
£¾Æ¾× ­»Æâ[¶È»ºÆ ̹ޯȽǼÇ?
Is spouse employed in a Government Department, State
Corporation Statutory Board or an Institution or receiving a
pension?
5. §Â Ç°ïÆà ¾øÉåÌƨ À¼úâŽÉ Ìè ¼?
·É+Ư¿Æ £¼±Ç+Ư ŒÕ¶È»¯¶Æ¶È¾Ç Á¶È¯È½ÉÇƯ¿Æ ?
Are you Iiving in Government Quarters ?
6. §Â ïɾºà Éæ´êÀ¨à ïÍåà ¨øÌÆ
è Š ¼ûľåɨà Ç°ïÆà ï¼ÀåںàºÉ
ë Èè¾à
Çå°ñ ÌâÌà»åɨø¾à/ ĸà¶Èƨø¾à/ ¡åƺ¾Æ¨ø¾à ÈÂÆú ¾Š ¦à
ÀèÎè¿ —ÌàºÇ :-
·É + Æ ¯ ¿Æ £¼±Ç+Æ ¯ ¶Æ ¶Èε¯Æ ¯ ¿+Æ ¯ ¿È‹Ý·Æ × £¾Æ ¾ × £¼±
»Ç¯Æ ¯ ¶Æ ¶ È‹Ý·Æ × £¾Æ ¾ × ·È»¶È±Æ ±´Æ ´ Ûν»Ç¸
±Î¹Š‹Ý·Æ × £¾Æ ¾ × ·ÈÞÁ¸¶Æ ¶ È‹Ý·Æ × ÍÁͽͶٺÆ
ÍÁ¶¸¶Æζ £¾Æ¾× ª×ºÆ ¹ˆÎ»¹Æ ̹½Æ½Ç¾Æ, £Á½Æ½È
ŒÁ¼+Ưο¶Æ ¶Ý¯:-
If you are in receipt of any other salary or any allowance from
Government Departments, State Corporation, Statutory Board
or Institution, give particulars.
(¡) ïɾºà Éæ´êÀ¨à ïÍåà ¨øÌèƊ ¼ûľåɨà Çæ.
(£) ÍÁÍ½Í¶ÙºÆ ÍÁ¶¸ºÆ £¾Æ¾× ª×ºÆ ¹ˆ ô¹Ç°
(a) Salary or any allowance Rs.

(¡å) —Éåͨ ¼ûľåɨà Çæ.

(¤) ¶ÈݺµºÇ͸ÇݯÆÐÇÈ» ¹ˆ ô¹Ç°
(b) Married allowance Rs.

7. Ç°ïÆà ¾øÉåÌƨ À¼ú⎠¾øȽå×¾à/ ¾øȽåÖ¾ù¾à Àĸ¨à

Àͺ ¡æºø ï¨å´ê ÀèÇ—Æ ÆêºëÆ.
£¼±Ç+Æ ¯ ŒÕ¶È»¯+Æ ¯ ¿È¾Æ Á¶ÈÜºÆ §¶Æ ¶ Èͻǯ¶Æ ¶ ÇÆ ¯ ¿Æ
º´ÆÕͺ ‰ÁÝºÆ çկο ·È¼¹ÆÚ¶¾Æ ÍÁ®ÕºÆ :
Following cages should be filled only by those officers living
in Government Quarters:
(¡) ¨ÉÇ ¼ú¾¨ Ìè´ Ç°ïÆà ¾øÉåÌƨ À¼úâŽÉ Ì萾àï¾à ¼ ƾ ɪ?
(£) ©¶ÆͶ¶È Û¶¾Æ £¼±Ç+Ư ŒÕ¶È»¯¶Æ¶È¾Æ Á¶È¯È½ÉÇƯ¿Æ ?
(a) The date from which Government Quarters are occupied
(¡å) Àò½å¾ À¼ú⎨Çæ ¼ ºæºïÍåºà ÍÉêïÈà À¼ú⎠¼ ƾ ɪ
(¤) ‰¼¶Ç¸ ЈŠÝ¹Æ¹Ç¿¼Ç¯ ¥Ý¯Æ¯È½ÉÇƯ¿Ç £¾Æ¾× ‰¼¶Ç¸
ЈŠÝ¹Æ¹Ç¿Ý´ ŒÕ¶È»¯¶Æ¶È¾Æ çˆ ¥Ý¯Æ¯È½ÉÇƯ¿Ç ?
(a) Whether as principal occupant or sharing quarters
(¡æ) ¨ëÈé ïªÉ¾àï¾à ¾Š ¦à ÀèÎè¿ —ÌàºÇ
(¥) ÁǴί ª×ºÆ ̯ÇկƯ¹Æ¹´Æ´Ç¾Æ, £¶ ŒÁ¼+Ưο¯Æ çÞ¯°
(b) If any rent is paid state particulars
[¡.À.Â./º°¹°¹Ç/P.T.O
 (¡æ) ÍÉê ï Èà À¼ú ⠎ ¾Š, Àò ½ å¾ À¼ú ⠎¨Çæïªà ¾Ä º¾ºë Ç Íå
ïÌàÉå Ìà»å¾Æ
(¦) ‰¼¶Ç¸ ЈŠÝ¹Æ ¹ Ç¿Ý´ ŒÕ¶È»¯¶Æ ¶ È¾Æ çˆŠÝ·Æ ¶ Ç¾Æ ,
‰¼¶Ç¸ ЈŠÝ¹Æ¹Ç¿Çȁ ̹»ÇÆ, ¹¶Œ¹Æ ̹»ÇÆ, ¹µÈÚÇÈܺȴºÆ
©¹¸Á½Æ Î ½¶Æ ¶Ý¯°
(d) If sharing, name, designation and place of employment of
principal occupant
8. ÃåÚÆåÉ ïÍåà ÌàÉå•ÀêÇæËÆå Ç°ïÆà ï¼Àåںàºëɨ/Ç°ïÆà
¡¾êªòÍÆ Èºà ÌâÌà»åɨ ïÍåà ¡åƺ¾Æ¨ Û¨øÆåÉ¨à ¨Ç¾ —´
ïÍåà —ÊòåÄ Éæ´êÀ¨à Ⱦ—´ Àĸ¨à Àͺ ¡æºø ï¨å´ê ÀèǗÆ
ÆêºëÆ.
ÁÇÀƯÆί¶Æ×ε ­ÇÆ £¼±Ç+Ư¶Æ ¶Èε¯Æ¯¿¶Æ¶È¾Æ /£¼± »Ç¯Æ¯¶Æ
¶È¾Æ / ·È»¶È±Æ±´Æ´Ûν»Ç¸ ±Î¹Š¾Æ £¾Æ¾× ·ÈÞÁ¸¶Æ¶È¾Æ
¹µÈ¯Æ¯ºÇƶƶ¹Æ¹´ÆˆÝ·Æ¶Ç¾Æ £¾Æ¾× ­ÇÆ ­»Æâ[¶È»ºÆ ̹޹Á
¼Ç¸Ç¾Æ º´ÆÕͺ ‰ÁÝºÆ çÕ¯¿Æ ·È¼¹Æ¹¹Æ¹Õ¶¾Æ ÍÁ®ÕºÆ :-
Following cages shall be filled only when the spouse is employed
in a Government Department/ State Corporation/ Statutory Board
or Institution or if on receipt of a pension.
(¡) Û¨øÆåÉ ¨Ç¾ ï¼ÀåںàºëïŒ/ ÌâÌà»åïŒ ïÍåà ¡åƺ¾ïÆà ¾Ä ÌÍ
Ìà»å¾Æ ïÍåà —ÊòåÄ Éæ´êÀ¨à ÈÂÆú ¾Š ¦Æ ÀèÎèïÆÈ ¨Ç¾ Ìà»å¾Æ.
(£) ¹µÈ¯Æ ¯ ºÇÆ ¶ Æ ¶ ¹Æ ¹ ´Æ Õ ¿Æ ¿ ¶Èε¯Æ ¯ ¿¶Æ ¶ ȁ £¾Æ ¾ × »Ç¯Æ ¯ ¶È
£¾Æ ¾ × ·È»¶È±Æ ± ´Æ ´ Ûν»Ç¸ ±Î¹Š £¾Æ ¾ × ·ÈÞÁ¸¶Æ ¶ ȁ
̹»ÝºÆ ¥´ÛºÆ £¾Æ¾× ­ÇÆ ­»Æâ[¶È»ºÆ ̹޹Á¼Ç¸Ç¾Æ ­»Æâ[
¶È»¶Æ ̶ÇйÆÚ¶Æ ¶»ÇÇȯƯ¹Æ¹ÕºÈ´ºÆ
(a) Name and place of Department, State Corporation or Statutory
Board or Institution where employed or where pension abstract
is prepared if on receipt of a pension.

9. ¡æÆ/ §Íê Ⱦ ÄåÌè¨ ïŒº¾Æ ïÍåà —ÊòåÄ Éæ´êÀ

£ÁÇÆ Ì¹ÞºÆ ºÇ¶Ç·Æ¶ ­»Æâ[¶È»ºÆ £¾Æ¾× ÍÁ¶¸ºÆ
Monthly Pension or Salary she/he is receiving

10. ÃåÚÆåÉ諭à/ ÌàÉå•ÀêÇæËÆåïª¾à ¾ùºÀ è ¨

ò åÇ ïɾà Éì ïÍåà
¼ú¨à¨Ìå¼ Éì ïÍåà Éæ¾à¼Åê Éì ïÍåà ÌèÆõÄ ¾øȽå×¾à/ ¾øȽåÖ¾é¾à
—Ìè¾à Àĸ¨à Àͺ ¡æºø ï¨å´ê ÀèÇ—Æ ÆêºëÆú.
±´Æ´Ûν»Ç¯¹Æ ‰ÇȷƶÈݹƹÁÇƯ¿Æ £¾Æ¾× ¶Èݺµâ½â ·É¯Æ¯´Æ
¹´ÆˆÝ¹Æ¹ÁÇƯ¿Æ £¾Æ¾× ÁÇÀƯÆί¶Æ ×ελ ¥À·Æ¶ÁÇƯ¿Æ
º´ÆÕͺ ‰ÁÝºÆ çկο ·È¼¹ÆÚ¶¾Æ ÍÁ®Õº:-
Following cages shall be filled only by those who are legally
separated, divorced or widowed:-
(¡) ¤Ìå—Æ ¾øïÆåàªÆ¨à Àè´ ¼Çæɾà Ì¿Íå ¾¶ºàºë Äê¼È¨à ïªÉ¾àï¾à¼?
(£) ·É¶Èº½¯Æ ¯´Æ´Î¿Ì»Ç½È¸Æ ͹ÇÈ¾Æ ‰¿Æο¯à¯ÆÐ¶Æ ¶Ç¹ÇȹÆÚ±Æ
̱¾â ̯ÇկƯ¹Æ¹Õ¯È½¶Ç?
(a) Is maintenance for children being paid on a Court Order
(¡å) ¤Ìå—ïÆà ¾øïÆåàªÆ¨à Àè´ ÃåÚÆåÉ´ ¾¶ºàºë Äê¼È¨à ïªÉ¾àï¾à ¼?
(¤) ·É¶Èº½¯Æ ¯´Æ´Î¿Ì»Ç½È ͹ÇÈ¾Æ ºÎ¸Œ¯ÆÐ±Æ ±ÉÁ¸ÇºÆ±ºÆ
̯ÇկƯ¹Æ¹Õ¯È½¶Ç?
(a) Is alimony for wife being paid on a Court Order?

11. ÉÆÌ ¡ÉêÇæó 18 ´ ¡¶ê Àè֕ ¼Çæïɨë ïÍåà 21 ´ ¡¶ê

¡—Éåͨ ªæÍæ¸ê ¼Çæïɨë Ìè› ¼?
18 Á»×¯ÆÐ¯Æ ¯ÉÀƹƹ´Æ´ ¤® º¯ÌÁÇÞ £¾Æ¾× 21 Á»×¯ÆЯÆ
¯É À Æ ¹ Æ ¹ ´Æ ´ ¶ÈݺµºÇ¯Ç¶ ̹® º¯ÌÁÇÞ ¥Ý¯Æ ¯ È¸Æ ½ ¶Ç
©¹×?
Is there a male child under 18 years or an unmarried female child
under 21 years?

¢Íº ¼æ¨àÉì ÌèÆÈàÈ ÌºñÉìºà, ¾øÉæǼúÉìºà ïºåǺëÇæ Âɺà, ¦Ä ïºåǺëÇæÉÈ ïÉ¾Ì¨à ¡æºø ÉêÉïÍåºà ¦à ÂÉ Äå ïÌàÉÆ ¨Ç¾ê Ⱦ
ï¼ÀåںàºëïŒ Àò½å¾øÆå ïɺ ¡ÀòÄå¼É ïÄÉæ¾ø Àò¨åÊ Àºòƨ ÄåÚªïÆ¾à ¼¾àɾ Âɺà ïÄÆú¾à Àò¨åÊ ¨Ç•.
ͺ½Æç½È»ÎÁ §®Îº»Ç¸×ºÆ ±ÇȻǸ׺Ǹ ¶¯Á̾¸ÆÞºÆ ¥¶Æ¶¯Á‹¾Æ ª×ºÆ ºÇ½Æ½Íº½Æ¹ˆ, £×¹½Æ½È ¶Ç
¹µÈÚÇÈÜºÆ ¶Èε¯Æ¯¿¶Æ ¶Î¾ÁݯÆÐ £½ÈÁȹÆ͹̸ÞºÆ ÌÁ¿È¹Æ¹Õ¶ÆׯÈͽ°
I declare that foregoing is a true and correct information and any change in this information will be notified to the Head
of my Department in which I will be serving.
¨åÚÆåÈÆ/Ìà » å¾Æ
£ßÁ¾¯ºÆ /¥´ºÆ ................................
Office /Place .................................................................................................................
¡ºà̾/ί̻ǹƹºÆ/ Signature

¼ú¾Æ/¶È¯¶È / Date ................................

H - 022255 Êòé Èâ¨å Ç°ïÆà Äê÷¸ ï¼ÀåںàºëÉ º¾ºëÇ/¹¶Œ¹Æ ̹»ÇÆ/ Designation.......................................................................................