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General
(A4* S. T. & E.) 2/77
(Internet Version)

Äê. ïÇ. 104 (4) Æ´ïºà ¡ÈåÃƾà ÀèÎÂ

è ¿ ïÆåÄê ¡â¨/̶ǴÇÆ ¥¾°/ Ref. No.

¡ÉÌå¾ ÉåÚºåÉ
·È° ‰° 104 (4) ¥ ¯ÈÀÆ ¥À¹ÆÚ¯¿Æ ¹½Æ½È» ¥Þ¶È £½È¯Æί
FINAL REPORT OF LOSSES UNDER F. R. 104 (4)

¡ÄåºñåâÊïÆà ïÈਊ.
Secretary to the Ministry of ........................................................................................................................
£Îº±Æ±È ̱»¾Ç¿Ý¯ÆÐ

Àè´Àº : —ª¸¨å“Àºø
‰¼¶È : £µ¯Æ¯Ç»Æâ £¶È¹¶È
Copy to : Auditor-General

1. ï¼ÀåںàºÉ
ë /ÌâÌà»åÉ
¶Èε¯Æ¯¿ºÆ/ç´Æնƶǹ¸ºÆ
Department/Corporation

2. ÀòåNJè ÉåÚºåÉ: ïÆåÄê ¡â¨ ¼ú¾Æ/Ͷ¶È/Date

̶Ǵ¯Æ¯ £½È¯Æί : ̶ǴÇÆ ¥¾°
Preliminary Report : Ref. No.

3. ¡ÈåÃÆ ÀèÎè¿ —ÌàºÇ/¥À¹Æ‰ Œ¹¼ºÆ/Particulars of loss–

¼ú¾Æ/Ͷ¶È/Date ïŒÈåÉ/Í·¼ºÆ/Time ÌèóÉì Ìà»å¾Æ/¥´ºÆ/Location

4. ¡ÈåÃÆ ÌèóÑÄ´ ïÍàºëÉì ¨Çæ¸ê/¥À¹ÆÚ ª½Æ¹´Æ´ éÀÆ·Èξ¯¿Æ/Circumstances in which the loss occurred :–

5. Éâ®åɨà ï¾åÌæΨøÈàȨà, ¡ºÀÌêÑĨà,

ÀòÄå¼Æ¨à ïÍåà ïɾºà ÉǼ¨à ïÍàºë ï¨å´¼
ƾ ɪ
¯¿â, ¯Á¸ºÈÎº, ¶Çº¶ºÆ, ¶ÁÞ¶¾Æ
£¾Æ¾× ‰½ ‰ÎÀ ¯Ç¼µºÇ¯ ª½Æ¹´Æ´¶Ç?
Is it due to fraud, negligence, delay,
omissions or other fault?
6. ïÀåÈèÌà ÉåÚºåïŒ ÌåÇåâÊÆ (ÉåÚºåïŒ Àè´Àº¨à ¡Ä긾à¾.)/Ì¹Ç‹Ò £½È¯Æߊ ÒݯƯºÆ (£½È¯Æߊ ‰¼¶È̻ǁν ¥Îµ¯Æ¯°)
Summary of Police Report (annex a copy of the report.)

H - 022255 (2004/10) Êòé Èâ¨å Ç°ïÆà Äê÷¸ ï¼ÀåںàºëÉ

 7. 7:4 7:5 7:6 7:7
¾æºøÉì Ãå¸à¶ÉÈ —ÌàºÇ/¥À¯Æ¯¹Æ¹´Æ´ ̹ÇݴƯ¿È Œ¹¼ºÆ/Details of Items Lost ¡ÈåÃÆ ÌèóÉì ¡É“ïÆà ¼Î Àòºø̊Àå¼¾ ¡ªÆ ïÍåà Äê. ïÇ. 105 (1) Æ´ïºà
ïÍåà º¨àïÌàÇæ ÀèÖÉæÆ ¡ÝºàÉæ‘Æå ¨ø×ïŠ —ƼŠ ɐ¾å¨Ä ÄêÈà ÀèÖÉæÆ
7:1 7:2 7:3
¥À¹ÆÚ Í·ÇƷƶ͹Ç× £¶ ¹¶È‹ÕºÆ ̱¾â £¾Æ¾× ·È° ‰° 105 (1) ¥¹ˆ ò¾¹Æ ̹޺¶È
£®µ¿ÁǸ £¾Æ¾× ¶Èݶƶ±Æ ̱¾â° ̹޺¶È
—ÌàºÇ/ŒÁ¼µºÆ/Description ¦à¨¨Æ/çÞ/ ÀòÄå¸Æ/̶Çί/ º¶È¹Æ‰´Æ´ ̹޺¶È
Original Cost
Replacement value or cost Value in terms of
Unit Quantity Approximate or estimated of repairs F. R. 105 (1)
cost at time of loss

2
8. ɪ¨èÉÆêºë ¾øȽå×¾à/¥À¹ÆÚ¯ÆÐ¹Æ Ì¹Ç޹ƹǸ §¶Æ¶Èͻǯ¶Æ¶ÇÆ/Officers Responsible–

8:1 8:2 8:3 8:4 8:5

¾Ä À¼—Æ ɪ¨ùïŠ ÌàÉÃåÉÆ ¾øȽåÖÆå´ —Çæ¼à½É —¾Æå¾ê¨íÈÉ ¨´Æêºë¨Ç ¡æºà¼?/ ¼¹êɊ ÀèÎè¿ —ÌàºÇ/
̹»ÇÆ ¹¶Œ¹Æ ̹»ÇÆ Ì¹Ç޹Ɖ ¶Îº нȶƶ §¶Æ¶Èͻǯ¶Æ¶Ý¯Æ̯¶È¼Ç¯ ¬á¯Æ¯Ç½ÆÞ ¶®´Î¸¯¿È Œ¹¼ºÆ/
Name Designation Nature of Responsibility ·´Áˆ¯Æί ©Õ¯Æ¯¹Æ¹´Æ´¶Ç?/ Details of Punishment
Was disciplinary action taken against the officer?
 3

9. ª¾à¾å ȼ ¾ùºøÄÆ ¨òèÆå Äåڪƾà ÀèÎè¿ —ÌàºÇ/©Õ¯Æ¯¹Æ¹´Æ´ ±´Æ´ ·´Áˆ¯Æί¿È ŒÁ¼ºÆ/Details of legal action taken–

¤Ìå—ïÆà ¾Ä/·É¶Èº½¶Æ¶È ̹»ÇÆ/Name of Court ¾¶ê ¡â¨Æ/ÁÀ¯ÆÐ ¥¾°/Case No.

¤Ìå—ïÆà ¾øïÆåàªÆ (Àè´Àº¨à ¡Ä긾à¾)/·É¶Èº½¯Æ¯´Æ´Î¿ (‰¼¶È ¥Îµ¯Æ¯)/Order of Court (Annex a copy)

10. ɪ¨øÉÆêºë ¾øȽå×¾àïª¾à ¡Æ¨Ç ªæ¾ùÄ´ ºùÇ¸Æ ¨Ç¾ ȼ Äê¼Èà ÀòÄå¸Æ/¥¶½ÆÐ¹Æ Ì¹Ç޹ƹǸ §¶Æ¶Èͻǯ¶Æ¶ÇƯ¿È´ºÈÝ·Æ×
£½ŒÕÁ¶½Æ̯¸¶Æ ¶ÉÇƺǸȯƯ¹Æ¹´Æ´ ̶Çί/Amount decided to be recovered from the officers responsible–

¾øȽåÖÆåïªà ¾Ä ¡Æ¨Ç ªæ¾ùÄ´ ¡æºø Äê¼È ¡Æ¨Ç ª¾à¾å ÀèÎèïÉÈ

§¶Æ¶Èͻǯ¶Æ¶ÇÆ Ì¹»ÇÆ £½Œ´ ÍÁ®ˆ» ̶Çί ©ÁÆÁÇÞ £½Œ´ ÍÁ®Õ̺¹×
Name of Officer Amount to be recovered How recovery is to be made

11. Ǩà˸ƨø¾à ïÍåà ¡æÀ Ìͺø¨Æ¨ø¾à ¡Æ¨Ç ªº Íæ¨ø ÀòÄå¸Æ/¯Ç¹ÆÚÞ¶È/ §¶Æ¶¶¼ÁǶ¶Æ¶È‹Ý·Æ× £½Œ´¯Æ爻 ̶Çί
Amount recoverable from Insurance/Guarantee–

(Äê¼È ¡¨ëÖ¾à) ÇæÀèÆÈà

(̶Çί ©á¶Æ¶È¾Æ) ô¹Ç° ..............................................................................................................
(Amount in words) Rupees

§ÀàÀêïŒ ¡â¨Æ/¯Ç¹ÆÚÞ¶È ¥¾/ ǨàË¸Æ ¨Ç¾ ȼ Äê¼Èà ÀòÄå¸Æ/¯Ç¹ÆÆÚÞ¶È ¡Æ¨Çªº Íæ¨ø Äê¼Èà ÀòÄå¸Æ/£½Œ´¯Æ 爻
Policy No. ̱»Æ»¹Æ¹´Æ´ ̶Çί/Amount Insured for ̶Çί/Amount recoverable

12. Äê. ïÇ. 104 (1) Ÿ Æ´ïºà Àºà¨Ç¾ ȼ Àרà˸ ĸà¶ÈÆ Ìç¼û ¡æºø ¡¾à¼Ä
·È° ‰° 104 (1) ¤ ¥ ‰¼¯Ç¼ºÆ ·È»ºÈ¶Æ¶ Œ±Ç¼Îµ±Æ ±Î¹Š £Îº¹ÆÚ
Composition of Board of Inquiry appointed in terms of F.R. 104 (1) b

ĸà¶ÈïÆà ÌåÄåÔ¨Æè¾àïªà ¾Š/±Î¹ §Þ¹Æ‰¸ÇÆ Ì¹»ÇÆ/ À¼—/¹¶Œ¹Æ ̹»ÇÆ/Designations

Names of members of the Board
 4
13. Àרà˸ ĸà¶ÈïÆà ¾øÚï¼àÊƾà (ÉåÚºåïŒ Àè´Àº¨à ¡Ä긾à¾)
Œ±Ç¼Îµ±Æ ±Î¹Š Œ¶¹ÆÚμ¯¿Æ (£½È¯Æߊ ‰¼¯Èλ ¥Îµ¯ÆЯ)
Recommendations of the Board of Inquiry (Annex copy of report)–

14. ¡¾åªºïÆà ¼û ïÄÉæ¾ø ¡ÈåÃƾà Ìèóъ ÉæÎæ¨àÑÄ´ ïÆå¼å ¡æºø ïÍåà ïÆå¼¾ê Ⱦ ÀèÆÉÇÉÈà
¥À¹ÆگƯο¶Æ ©Õ¶Æ׿ƿ £¾Æ¾× §¶ÆͶ±È¶Æ׿ƿ ·´Áˆ¯Æί¯¿Æ
Steps taken or proposed to be taken to prevent similar losses in the future

.......................................................................................
¼ú¾Æ ï¼ÀåںàºëïŒ Àò½å¾øÆå/ÌâÌà»åïŒ ÌÃåÀºø.
Ͷ¶È ........................................... ¶Èε¯Æ¯¿¶Æ ¶Î¾ÁÇÆ/ç´Æնƶǹ¸¶Æ ¶Œ±Ç¸ÇÆ°
Head of Department/Chairman of Corporation.
Date

15. Ãå. ¾ø. ïÈà. ïÆåÄê ¡â¨

¶È° ̱° ̶ǴÇÆ ¥¾° ................................
S. T. Ref. No.

¢¼úÖÀºà ¨Ç•.
£Ù¹Æ¹¹Æ¹´ÆÕ¿Æ¿×.
Forwarded.

¡ÄåºñåâÊïÆà ïÈਊ.
Secretary to the Ministry of ........................................................................................................................
£Îº±Æ±È ̱»¾Ç¿ÇÆ°