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S'\"'L. ·O.1t94~R..L.'O.1I2006 -sm7'1 182286H.•'0. 5+lANNEXU. e ~I

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AFFIDAVIT TO BE FU~ .; 1 ,1\!)':. ~ID rl~~LO G(j'! «M~ T~ 9~PER

u .r-: lIef~e t ~)Returning Officer;.OW..JUO,CIALJ. . SlIO.MPDU":'" AIIDttItA~

for election to A~.?..:: A.5S~ ..Q~ : (name of the House)

from \1.e.JLgJf.~ .,: constituency-

(Name of the Constituency'] .

1._ R9_m ..~sb J}?~Jg.~:r ~n/d9tlshtedwire_:_ .._.@q..~q.~q~.: .of

..............c~OU~.Q,~a.m \l~.\L~ ..: aqed.. ..3~3 years. resident of

..............~Q.u..':'6~~~Y.D: .. candidate at the above election, do

45093I

)'.i ': 3ttii .~Jill DB 2010

hereby solemnlyaffirm and state on oath asunder:-(Strike out whichever not applicable)

- (1) The following case(s) is/are pending against me in which cognizance has been taken by thecourt:-

-(i) Section of the Act and description ofthe offence for which cognizance taken:

(ii) The Court which has taken cognizance:

(iii) Case No. :

(iv) Date of order of the Court taking cognizance:

(v) Details of appeal(s) / appJication(s)for revision, etc.• if any. filed against above ordertaking cognizance:

(2) That I give herein below the details of the assets (immovable. movable. bank balance. etc.) ofspouse. my dependents and myself":

298

A. DETAILS OF MOVABLE ASSETS

(Assets in joint name indicating the el\tent of joint ownership will also have to be given)

S. Description Self Spouse(s) Dependent- Dependent- Dependent-No. Name(s) 1 Name 2 Name 3 etc. Name

(i) Cash10... D75V,- 2..0/O"L5D. - -- -

(ii) Deposits in Banks,Financial Institutions'and Non-Banking - - - .Financial Companies - -

(iii) Bonds, Debenturesand Shares incompanies - - - --

(iv) Other financialinstruments, NSS,Postal Savings, L1C :l.~ 10Policies, etc. I om>~ I 075D, - - .

-(v) Motor Vehicles

(details of make, eSl-)e(Detc.)

(vi) Jewellery (give -details of weight and _value) :10# ca:f~ 3~ ~I~

--l

. -(vii) Other assets, such .

as values of claims Iinterests - - - --

Note: Value of Bonds I Shares I Debentures as per the latest market value in Stock Exchange inrespect of listed companies and as per books in the case of non listed companies should begiven.

'!J!;.(~:1iof the candidate.

299

,

B. DETAILS OF IMMOVABLE ASSETSL

[Note : Properties in joint ownership indicating the extent of joint ownership will also have to beindicated}

s. Description Self Spouse(s) Dependent- Dependent- Dependent-No. Name(s) 1 Name 2 Name 3 etc. Name

(i) Agricultural Land -L.ocation(s) -Surveynumber(s) -Extent (Totalmeasurement) -Currentmarket value .

(ii) Noo-Agricultural Land -~o.~Location(s) -Survey

number(s) -Extent (Total 1-1'V'measurement) -Currentmarket value

(iii) Buildings (commercial andresidential) -Lo~tion(s)-SUoveyI door n~~s) -Extent (Total meas rement)-Current market valu- ,.

(iv) Houses I Apartment~i etc. - .Location(s) -Survey I doornumber(s} -Extent (Totalmeasurement) -Currentmarket value

(v) Others (such as interest inproperty)

3 I give herein below the details of my liabilities I overdue to public financial institutions andGovernment dues: -

[Note: Please give separate details for each item]

(a) (i) Loans from Banks

Name & address of Bank I Amount outstandingFinanciallnstitution(s) I as on .Department( s)

S.No. Description

(ii) Loans from financial institutions

(iii) Government dues

a) Dues to departments dealing withgovernme ccommodationDues to dep rtments dealing with

~~~~~QlY of water

300

..•. '.

·:-, .-( . c) Dues to departments dealing with

supply of electricity

d) Dues to departments dealing withtelephones

e) Dues to departments dealing withgovernment transport (includingaircrafts and helicopters)

f) Other dues, if any (

S.No. Description Name & address of Bank / Amount outstandingFinancial Institution(s) / as on ........................Oepartment(s) .'

(0) (i) Income Tax including surcharge

~.,[Also indicate the assessmentyear upto which Income TaxReturn filed. Give also PermanentAccount Number (PAN))

(ii) Wealth Tax [Also indicate theassessment year upto whichWealth Tax return filed.] - -

(iii) Sales Tax [Only in case ofproprietary business]

(iv P-roperty Tax , ,

) .

(4) My educational qualifications are as under :-

(GIVE OETAJ[S OF SCHOOL AND UNIVERSITY EDUCA nON) n ' ;r- [l eo((Name of SchOol I uni~ity and the year in which the course was completed should also be

given.) ~-:\. ./

H." B~ OSmCl.Jg.OW-re""ft·Hyq.· ~PONENT

VERI FICA TION

I, the deponent above named, do hereby verify and declare that the contents of this affidavit are trueand correct to the best of my knowledge and belief; no part of it is false and nothing material has beenconcealed there from.

IVerified at ... -r . this the day of . '. 200 .

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

~Sl~:DIISL No. 301EGA

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FORM 26 (SEE RULI: 4A ",!;~~~L AIIDtlRANADESH

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158287 P -,' IJU.~_..D8-2-&tO.,.... ..

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Affidavit/ to be furnished by the candidate ~~ the Returning Officer for election to..A.~..: (name of the House) from.~e.llQ.iUnstituenCy (name of the constituency)

() L f'i).,.! ~ / .' ' ,I, ..K.Q.roe.s.r; .... f.-:'1~'(I, SOnldatJ~htedwife of ...~~o..~ .... aged about ~.~.years, residentof 9'O'u..-::?O'XQ.:rn.: candidate at the above elec'tlon, do hereby solemnly affirm/state on oathas under:-1. Iam/am not accused of any offence(s) punishable with imprisonment for two years or more ina pending case(s) ,in which a charge(s) has/have been framed by the court(s) of competentjurisdiction.

If the deponent is accused of any such offence(s) he shall furnish the following 'information:

)0 (i) Case/First information reports No.1 Nos ,...... ./ (ii) Police station(s) ~ District(s) .

State(s) .(Iii) ~Sec1l6ri1s)' of the 'concerned ct(s) arid short description of the offence(s) for which thecandidate has been charged.......... -

(iv) Court(s) which framed e charge(s) : .(v) Date(s) on which the harge(s) .

(vi) Whether all or any of the proceeding(s) have been stayed by.any court(s) of competentjurisdiction

-............................................................................................................................................

2. I have been/have not been convicted of an offence(s) [other than any offence9s) referred to inSUb-section (1) or sub-section ), or covered in sub-section(3), of section 8 of the Representation ofthe People Act, 1951 (43 of 19 1)] and sentenced to imprisonment for one year or more.

If the deponent is convicted an tunished as aforesaid, he shall furnish the following information:

(i) Case/First informati n reports NoJNos , .(ii) Count(s) which pun shed : .(Hi) Police station(s) District(s) State(s) .(iv) Section(s) of the concerned Act(s) and short description of the offence(s) for which the

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,

VERIFICATION

I. the above-named deponent. do hereby verify and declare that the contents of this affidavit are trueand correct to the best of my knowledge and belief, no part of it is false and nothing material has beenconcealed therein.

Verified at this day of ~o .

Signature of deponent

Note: "The columns in this Form which are not applicable to the deponent may be struck off."

291

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