NOI{INATION PAPER Etedian to thc House at ke pe.pte e{
STRI(E OFI PART I OR PART II BELOW WHICHEVER IS NoT AIPLICABLE PART I
(To be usd by candidare sd up by rcognr J nonrnaG a\ : cddLdiie for elsron b !6c House of $c Peopte fiom crrdidde tum- ...... /... rJde,,rno,hq$usbrnd!
Hi./Hdmm-se eEy'd stNo...... -pinNo ... .of .r rhe ddoml 6ll fo...... (Allembty connnuency comprised wirhin) ...... Pa.lEmenbry Conrituency.
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PART II
(To be lscd by cmdrd,rc NOT s( up by r4ognisd pohcat 6\t ,"t " ." t55 oLr rd!(o'xrr.r n
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PART NI I.Lhcc.ndidatenentronediPMtPrnn(srrkcotrrvhi.hisnorrfplcrbc)rsenrrorh^
G) rLiat I am r cilpln olhdh&d havenor ac'+rcd rhe ciLirnshrpof,ny foriln srare/counlry. b!hrr hr{.nnplcrd. 7a( VER IS NOT APTLICABLE]
shre rnd r|[l re sl,i$ot re\ened fo, rh! ibolc 's , r.rL ' 'l,r I
!hi.h n noL trptjti.rbk) rnd rhir rhc ,\PPll- .,". n!ry,-a I r .Cat I rlso dcclarc rhd Ih.ve nor b.c.. rnd shi ,or bc no.r nrDd.s a candddc d lenerrrcb.rodlhe byc.ctocrons bci,rg hdd smtrtrMcously, ro Lhc Hous orLhe pcople LrD( rso Pa irmenury Con{uercics. 't/-\,'€a o",.S 14 /9 I ScoE our rhc lods aseobtt.on$rucn.].ompnsedwnhin.,n rhe c* orJanmu rndK$hmii andrma! lnd Nicobar htands, chandigrh, Dldo rnd N,8!r Haveh. Danan md Diu rnd iscorc our rhis pangmph, if noL :pplicable Itscore out the wolG norapptrcabte N.B.-A Eogn'ed pot'hatpany. mqns a potiricatpany doln$d by |ne Et@uon Comnssion undcr rhe El-uon Symbols (Re*naron and Altormeo Oder. l96B in de SbE mncened. PART IIIA (To be filled by $e candidaE) ( I ) wlelhd dE ddidare (i) has b@n convicGd (a) oa any otrenc(9 under snb sarion(l )r or (b) for contnvctuon of uy laq specificd in lub sedbn(2). of sccbo! 8 ot fte Rcp6ematron of rlc P@ple Acl, t951 (.13 of l95t). or t 0, hrs bden dJneicred ro' rn) other olrcnccc) for whrch hc hxs becn scnrcnccd ro mpnsonnrm lor tvo I'cxs or norc If tle auswer is YcJ', rhc canddrLo shall fumah the Lll.ei'rg inf(rmation: t) c$e/hisr inrormltion repon No.Nos. 4 rl s .r'.r n.'l e.. rcen ed Ac I r.,l brifldc -. priol orr,r, of, (, r. ' '.. ' (i\r DrreGr of dr lonL lron(r I (.). L (.) qh" h on\ide!,h. xidd.r'... nrceJ r icdte y'er.ol of.np'ro' rr'J^' ol ^.rPrh\'r"rr,l '.i, \'r"'n un(tj...... /...... rl,xv i.or p,,, '\ri.rr"re',of/L$ / '\.ii'wd mrxpp..,'A,y'"'eJzc,n.'Jbo\e.o$'.'orL, .'\' nre p.f,d.y. 1'r 1'o i tor 'd /or -pp. ' fi. NJmr ur rhe .o betorc qhtr | rpFtrl(\)tunfli.ronL\) for Le\isior nlcd 'r(s) 'l'e whedF d e \'.d rpn*l.r'dpt I ',lJ\.becr,l-pordo o. ... . 'vafl Fndins / (rn) IrLhc srd rppeJl(s/applicaLionG) lor rc!6,o. lus,hrrebeen 'b'Ndrrofodcn.rrJ.e (2) wlrcrhcr rhc cMddde is holding rny office ol prctu undcr rlr Gov.mhenr ol Indir or srde coremnem? Or6No) .llJc dcxf.v lcor'.. l--l (3) wbc'hd rhc cMdidare hrs been dalaFd msolvcDr by xny coh? ...... (rr.sNo) .lf \.. lc b.4 d'.. g 01 in o.!e1,j 'a\ 'r (.4) wl)cLher fie cdd rle under allesilDce or adhcrcncc ro M torcrgn.ountryt ,''' ',', '',,,', ''', (},6No) {yos,Brlcdeuilr... .. (5) wlether rhe candidrle tus ben dn!{alifrcd undd se.uon 3A of the srid Acr by r ordd orlhc Picrdent?...... (t?aslNo) Ir)6.$ellrn"liJ'q\..hdijq'Jlfied ...... (6) \\4reLher de cMddrre Brs dnmnsed for conplion or for dsloydry wh c holdmg dniceunderrheGoremmenrof lndiaor desovcmnc.rof anys'ar?...... 0r6n!o) lrl.. il. ie r.'"hrr,nir 1...... wilh the Govemnd cnhd o) wlElher Lhe cmdidrte ha\ my Nb\khng connrc(t 'n ind,vduil carrciy or bl run or pdrrcrshil n uhich thc c0ndidde hns a shlrc for supply of my good! ro Lha( Gorermc or for execurcn of vorks mdemkcn bv $rt covcdrenlt ...... (}d/No) Ifyes. wnb Nhicn Govcrmenl and dcrails oisubr$ins@ntm(t ,' (8) whelhd |ne cand at r a nranaging lgcnL or mdmgcr or se'rcLdv ol mv conrpar, oi o.porarioD (olnei $dr a cooPe.atrve society) nr thc capilil ot *hich the ccnml Govemem or sL0le Covemmcnl has not les lhan twcnLv_iivc Perccrt shre? ,' lfYes, w,|n which g.vcdncnr lnd thc dcriils rhcreor (9) wberher the cmdidarehas been disqualdcn bv rhe comnisson u.dcr Secton I0A ot thesridAcL...... C, PART IV by theReu irs Orfi.d) This nominrlion *rs deliveEd ro ne by rhe *.ddidale/proposer. (name or iANTIFTLTI\i'icoi I lcf lr, ''''!'lr_i1 \:r')]r'rr' PART V Dc.ision olRelumng officer AcaprrE orReje.ans lhe NodnrLion Paper I have exrdrtd Lhn nonMhon peper n accorddnce with s4don 36 of the Rcprcscn(arion ol the People Acr, 1951(43 of l95l) ud decide as folloqsi 1|. PARTVI Rec.ipl for NonnErion pap.rand Notn.e oI Scr uriry INDIA NON JUDICIAL Government of Karnataka 3 6 e-Stamp S CGrtiticate No. IN-KA86427777439879R l Certificate Issued Date 02-Apr-2019 12:16 PM ?! Account Reference NONACC (FI)/ kacrsflOS/ SHANIWAR KHOOT1/ KA-BL 5. Unique Doc. Reference SUBIN-KAKACRSFL0803449460540070R I Purchased by DHANANJAY RAJARAM PATIL 5 Description of Document Article 4 Affidavit Description AFFIDAVIT Consideration Phce (Rs.) 0 (Zero) ? * First Party DHANANJAY RAJARAM PATIL c Second Party RETURNING OFFICER BELGAUM PARLIMENTARY 5 Stamp Duty Paid By DHANANJAY RAJARAM PATIL I Stamp Duty Amount(Rs.) 100 (One Hundred only) ; AuthorlsaoSlgnatory 3 The Markan-:!? . * v :la Multi Purpose Co-C . iocf ty Ltd., Kangrai K.H. Br. Si*, iniwar Khoot, I BELGAUM. i i 5 Ploase write or type beiuw this line i a - "FORM-26 s'i (See rule 4A) 3 davit to be filled by the candidate along with nomination paper 5 before the returning officer for election to 02-BELAGAVI LOKASABHA From PARLIAMENTARY CONSTITUENCY. I 5 i Statutory Alen: • Tin .lutr-rriiciv of this Stiimp Ccnrfcafo shouKl Dt* vent no .it 'WWW ^i>-tl<'»tnmp.oonr Any (Sscwpancy in no oetaiis on Ih.-s Cert-tu m anil... iwnilalilo on Ihc wetailt* rorwn. n inva'd ? ri»’ '""im Of ol'c-i:kino the iefllluniicy in on ini’ users d the coniiu .in j in cufm ol unv aiSCrunnnw ploase in’orir trw Cfintprifunl Auh'dity * 1/ DHANAJAY RAJARAM PATH, Age 42 Years, resident of At: Channewadi, Post: K. Nandagad, Tq: Khanapur, Dist: Belagavi a candidate at the above Election, do hereby solemnly affirm and State on oath as under (1) lam an Independent Candidate. (2) My name is enrolled in 02 BELAGAVI GENERAL ASSEMBLY CONCSTITUENCY IN KARNATAKA, at Serial No. 631 in Part No. 155. (3) My contact telephone number(s) is 7899094108 and my e-mail id (if any ) is [email protected], 2] Face Book A/c: Dhananjay Patil, 3] Whatsapp : Dhananjay Patil. (4) Details of Permanent Account Number (PAN) and status of filling of Income Tax return : Names PANSI The financial year for Total income which the last Income- shown in Income - No. Tax return has been filed tax return (in Rupees) 1 Self AZDPP3459L NIL NIL Dhananjay Patil 2 Spouse- Nil Nil Nil Vanashri Dhananjay Patil 3 Dependent-1 (Mother) Nil Nil Prabhavati Rajaram Patil 4 Dependent-2 Nil Nil Nil _ Durvank Dhananjay Patil^ 5 Dependent-3 NilNil Nil Falguni Dhananjay Patil Note: It is mandatory for PAN holder to mention PAN and in case of no PAN, it should be clearly stated "No PAN allotted". (5) Pending criminal cases (i) I declare that there is no pending criminal case against me. (Tick this alternative if there is no criminal case pending against the Candidate and write NOT APPLICABLE against alternative (ii) below) OR (ii) The following criminal cases are pending against me: (If there are pending criminal cases against the candidate, then tick this alternative and score off alternative (i) above, and give details of all pending cases in the Table belo 2 I * A TABLE (a) FIR No. with name and address NIL NIL NIL of Police Station concerned (b) Case No. with Name of the Court NIL NIL NIL (c) Section(s) of concerned Acts/Codes NIL NIL NIL involved (give no. of the section e.g. Section of IRC, etc, (d) Brief description of offence NIL NIL NIL (e) Whether charges have been NIL NIL NIL framed (mention YES or NO) (0 If answer against (e) above is YES, NIL NIL NIL then give the date on which charges were framed (9) Whether any Appeal/ Application for NIL NIL NIL revision has been filed against the proceedings(Mention YES or NO) T / \ (6) Cases of conviction 4 > 0,': «_ 10) 1 declare that I have not been convicted for any criminal offence. (Tick this alternative, if the candidate has not been convicted and write NOT O-Y APPLICABLE against alternative (ii) below) RNK OR (ii) I have been convicted for the offences mentioned below: (If the candidate has been convicted, then tick this alternative and score off alternative (i) above, and give details in the Table below) \ 3 4 TABLE (a) Case No. NIL NIL NIL (b) Name of the Court NIL NIL NIL (c) Sections of Acts/Codes NIL NIL NIL involved (give no. of the Section, e.g. Section of IRC, etc.). (d) Brief description of offence for NIL NIL NIL which convicted (e) Dates of orders of conviction NIL NIL NIL (0 Punishment imposed NIL NIL NIL (9) Whether any Appeal has NIL NIL NIL been filed against conviction order (Mention YES or No) (h) If answer to (g) above is NIL NIL NIL YES, give details and present status of appeal (6A) I have given full and up-to-date information to my political party about all pending criminal cases against me and about all cases of conviction as given in paragraphs (5) and (6). [candidates to whom this Item is not applicable should clearly write NOT APPLICABLE IN VIEW OF ENTRIES IN 5(i) and 6(i), above] Note: 1. Details should be entered clearly and legibly in BOLD letters. 2. Details to be given separately for each case under different columns against each item. 3. Details should be given in reverse chronological order, i.e., the latest case to be mentioned first and backwards in the order of dates for the other cases. 4. Additional sheet may be added if required. * 4 4 5. Candidate is responsible for supplying all information in compliance of Hon'ble Supreme Court's judgment in W. P (C) No. 536 of 2011. (7) That I give herein below the details of the assets (movable and immovable etc.) of myself, my spouse and all dependents: A. Details of movable assets : Note: 1. Assets in joint name indicating the extent of joint ownership will also have to be given. Note: 2. In case of deposit/investment, the details including Serial Number, Amount, date of deposit, the scheme, Name of Bank/Institution and Branch are to be given. Note: 3.Value of Bonds/Share Debentures as per the current market value in Stock Exchange in respect of -listed companies and as per books in case of non-listed companies should be given. Note: 4. 'Dependent' means parents, son(s), daughter(s) of the candidate or spouse and any other person related to the candidate whether by blood or marriage, who have no separate means of income and who are dependent on the candidate for their livelihood. Note: 5. Details including amount is to be given separately in respect of each investment Note: 6. Details should include the interest in or ownership of offshore assets. Explanation,- For the purpose of this Form, the expression "offshore -A assets" includes, details of all deposits or investments in Foreign banks and any other body or institution ■ abroad, and details of all assets and liabilities in -PATH. \ ■ MOIST foreign countries'; .‘10 \ Cl 2 /' DESCRIPTION SEIF SPOUSE HUF DEPENDENT- I I DEPENDENT-2 1 DEPENDENT-3 0) Cash in hand 25,000/- «»,000 Nil Nil NIL NIL IDBI Bjnk Canara Ban-; Nil Nil NIL NIL (ii) Details of deposit in bank Saving A/c accounts (FSRs, Term A/c A/cNo. A/c HO. 16668 101l040a»Sff>D5 deposits and all other Rs.60,392/- Ps. 4,163/- types of deposits V' including Sarvada sav,n9 Saivada Multipurpose accounts). Deposits with Multipurpose Co- Co-Operative Operative Society Financial Institutions, Society Non-Banking Financial Saving A/C Saving A/c No. A/c No. 51 275 Companies ’ and R5. 56,170/- Rs. 500/- Cooperative societies and Flxed Deposit Fixed Deposit Amount the amount in each such Rs. 3,80,000/- deoosit Rs.7,19,880/- - Wee roo 1 I T'AkOvOTO Co of BonK L*4V 0 0200 i|oi|>r^O0 tr t \u L Dt+oit l o\ lnvofo\ *■" ( 6«*> (iv) Details of investment In UC NIL NIL NIL NIL NIL NSS, Postal saving. Rs. 1,20,000/- 1 Insurance Policies and Investment in any Financial instruments In Post office or Insurance Company and the amount (v) Personal loans/advance NIL NIL NIL NIL NIL NIL given to any person or entity including firm, company, Trust etc. and other receivable from debtors and the amount (vl) Motor vehides/Aircra fts/ 2 Wheeler 4 wheeler NIL NIL NIL NIL Yachts/Ships (Details KA-22-E 0109 Ka-22- of Make, registration Rs. 20,000/- MB01684 number, etc. year of Rs. purchase and amount) 11,00,000/- (VII) Jewellery, bullion NIL 40 Gram NIL NIL NIL NIL and valuable thing(s) Rs. (give details of weight 40,000/- and value) (viii) Any other assets such as NIL NIL NIL NIL NIL NIL value of claims/interest (ix) Gross Total value NIL NIL NIL NIL B. Details of Immovable assets: Note: 1. Properties in joint ownership indicating the extent of joint ownership will also have to be indicated Note: 2. Each land or building or apartment should be mentioned separately in this format Note: 3. Details should include the interest in or ownership of offshore assets. SI. Description Self Spouse HUF Dependent- 1 Dependent-2 Dopcndent-3 No (i) Agricultural NILNILNIL NIL NIL NIL Land Location(s) Survey number(s) NIL NIL NIL NIL NIL NIL Area (total ‘ * measurement in acres) Whether NIL NIL NIL NIL NIL NIL inherited property (Yes or No) 6: 1 l ** A SI. Description Self Spouse HUF Dependent- 1 Dependent-2 Dependcnt-3 No Date of 17-03-2016 NIL NIL NIL NIL NIL Purchase in case of self acquired property Cost of Land 31,50,0007- NIL NIL NIL NIL NIL (in case of purchase) at the time of purchase Any NIL NIL NIL NIL NIL NIL investment on the land by way of development construction etc. Approximate 42,00,000 NIL NIL NIL NIL NIL Current Market Value (ii) Non NIL NIL NIL NIL NIL NIL Agricultural Land Location (s) Survey numbers (s) Area (Total NIL NIL NIL NIL NIL NIL measurement in sq ft) Whether NIL NIL NIL NIL NIL NIL inherited property (Yes or No) Date of NIL NIL • NIL NIL NIL NIL purchase in case of self acquired property Cost of land NIL NIL NIL NIL NIL NIL (in case of purchase) at the time of purchase Any NIL NIL NIL NIL NIL NIL investment on the land by way of development construction etc. 7 4 si. Description Self HUF Dependent-1 Dependent-3 No Approximate NIL NIL NIL NIL NIL NIL current market value (iii) Commercial NIL NIL NIL NIL NIL NIL Buildings^ (including apartments) - Locations (s)- Survey numbers (s) Area (total NIL NIL NIL NIL NIL NIL measurement in sq ft) Built-up Area NIL NIL NILNIL NIL NIL (total measurement in sq ft) Whether NIL NIL NILNIL NIL NIL inherited property (Yes or No) Date of NIL NIL NILNIL NIL NIL Purchase in case of self acquired property Cost Of NIL NIL NIL NIL NIL NIL property (in case of purchase) at the time of purchase Any NIL NIL NIL NIL NIL NIL Investment on the property by way of development construction etc. Approximate NIL NIL NIL NIL NIL NIL current Market Value 8 4 SI. Description Self Spouse HUF Dependent-1 Dependent-2 Dependent-3 No (iv) Residential NIL NIL NIL NIL NIL NIL Buildings (including apartments) (Location (s) Survey Numbers (s) Area (Total NIL NIL NIL NIL NIL NIL Measurement in sq ft) Built up Area NIL NIL NIL NIL NIL NIL (Total Measurement in Sq ft.) Whether NIL NIL NIL NIL NIL NIL inherited property (Yes or No) Date of NIL NIL NIL NIL NIL NIL Purchase on case of self acquired property Cost Of NIL NIL NIL NIL NIL NIL Property (in V- case of V purchaser) at the time of purchase Any NIL NIL NIL NIL NIL NIL investment on the land by way of development construction etc (v) Others (such NIL NIL NIL NIL NIL NIL as interest in property) (vi) Total of NIL NIL NIL NIL NIL NIL current market value of (i) to (V) above 9 k (8) I give herein below the details of liabilities/dues to public financial institutions and government:- (Note: Please give separate details of name of bank, institution, entity or ind'vidual and amount before each item) a. Description Self Spouse HUF Depcndent- Dependcnt- Dependent- No 1 2 3 (iv) Loan or dues to State Bank of Canara Bank NIL NIL NIL NIL Bank Financial India Institution fs) Name of bank or Housing Loan Vehicle Loan Financial Instruction Amount Rs.26,00,000/- Rs. 9,20,000/- Outstanding, Nature of Loan Loan or dues to NIL NIL NIL NIL NIL NIL any other individuals/entity other than mentioned above Name (s) Amount Outstanding Nature of loan Any other v7 • >ir liability 1 V-i Grand Total of No liabilities :5/LCi (") Government (A) Has the Deponent been in occupation of Dues accommodation provided by the Government at any KA Dues to time during the last ten years before the date of departments notification of the current election ? dealing with Government (B)If answer to (A) above is YES, the following accommodation declaration may be furnished namely:- (i) The address of the Government accommodation: (ii) There is no dues payable in respect of above Government accommodation, towards- 10 (a) rent (b) electricity charges; (c) water charges: and (d) telephone charges (date) [the date should be the last date of the third month prior to the month in which the election is notified or any date thereafter]. Note- 'No Dues Certificate' from the agencies concerned in respect of rent, electricity charges, water charges and telephone charges for the above Government accommodation should be submitted. (iii) Dues to NIL NIL NIL NIL NIL NIL department dealing with Government transport (including aircrafts « and helicopters) (iv) Income Tax dues NIL NIL NIL NIL NIL NIL (V) GST dues NIL NIL NIL NIL NIL NIL (Vi) Municipal/property NIL NIL NIL NIL NIL NIL tax dues (vii) Any other dues NIL NIL NIL NIL NIL NIL (viii) Grand Total of all NIL NIL NIL NIL NIL NIL Government dues (ix) Whether any NIL NIL NIL NIL NIL NIL other liabilities are in dispute if so mention the amount involved and the authority before which it is pending. (9) Details of profession or occupation: (a) Self : Service (b) Spouse : Service 11 > (9A) Details of source(s) of income: (a) Self : 2,41,000/- (b) Spouse : 4,80,000/- (c) Source of income, if any, of dependents,...... (d) Contracts with appropriate Government and any public company or companies (a) details of contracts entered by the candidate...... (b) details of contracts entered into by spouse...... (c) details of contracts entered into by dependents...... (d) details of contracts into by Hindu Undivided Family or trust in which the candidate or spouse or dependents have interest...... (e) details of contracts, entered into by Partnership Firms in which candidate or spouse or dependents are partners...... (f) details of contracts, entered into by private companies in which candidate or spouse or dependents have share...... (10) My educational qualification is as under: B. com completed in B. K. College Belagavi in the year 1997. (Give details of highest School / University education mentioning the full form of the certificate/ diploma/ degree course, name of the School /College/ University and the year in which the course was completed.) PART-B (11). ABSTRACT OF THE DETAILS GIVEN IN (1) TO (10) OF PART - A: 1. Name of the candidate Shri. Dhananjay Rajaram Patil 2. Full postal address At: Channewadi, Post: K. Nandagad Tal: Khanapur, Dist: Belagavi. 3. Number and name of 02 Belagavi Karnataka the constituency and State 4. Name of the political Independent Candidate party which set up the candidate (otherwise write 'Independent') 5. Total number of NIL pending criminal cases 12 4 6. Total Number of cases in which convicted NIL 7. PAN of Year for which last Total Income Shown Income Tax Return filed (a) Candidate AZDPP3459L NIL (b) Spouse NIL NIL (C) HUF NIL NIL (d) Dependent NIL NIL 8. Details of Assets and Liabilities (including off shore assets) in rupees Description Self Spouse HUF Dependent-Dependent Dependent 1 2 3 A. Moveable Assets (Total NIL NIL NIL NIL NIL NIL value) Immovable Assets Asset - B. NIL NIL NIL NIL NIL NIL O: >« Purchase Price of self- NIL NIL NIL NIL NIL NIL * * acquired immovable property II Development/constructio NIL NIL NIL NIL NIL NIL n cost of immovable property after purchase (if applicable) III Approximate Current Market NIL NIL NIL NIL NIL NIL Price - (a) Self-acquired assets (Total Value) (b) Inherited assets (Total Value) 9 Liabilities NIL NIL NIL NIL NIL NIL (i) Government dues (Total) NIL NIL NIL NIL NIL NIL 13 ► Note: 1. Affidavit should be filed latest by 3.00 PM on the last day of filing nominations. Note: 2. Affidavit should be sworn before an Oath Commissioner or Magistrate of the First Class or before a Notary Public. Note: 3. All columns should be filled up and no column to be left blank. If there is no information to furnish in respect of any item, either "Nil" or "Not applicable", as the case may be, should be mentioned. Note: 4. The affidavit should be either typed or written legibly and neatly. Note: 5. Each page of the Affidavit should be signed by the deponent and the Affidavit should bear on each page the stamp of the Notary or Oath Commissioner or Magistrate before whom the Affidavit is sworn. I Know the Deponent fa&VOcaycL, cy> o H SWORN TO BEFORE ME M. G. PATIL, b.Coc.t, ll9. (Spg ADVOCATE & NOTARY Q be - t 2 APR ?019 O \ LA'A.'! Reg. At SL. No £ 15 INDIA NON JUDICIAL Government of Karnataka e-Stamp Certificate No. : IN-KA86531198531275R Certificate Issued Date : 02-Apr-2019 01:08 PM Account Reference ; NON ACC (FI)/ kacrsflOS/ SHANIWAR KHOOT1/ KA-BL Unique Doc. Reference : SUBIN-KA KACRSFL0803655643807106R Purchased by : DHANANJAY RAJARAM PAUL Deschption of Document : Article 4 Affidavit Description : AFFIDAVIT Consideration Price (Rs.) : 0 (Zero) First Party : DHANANJAY RAJARAM PAUL Second Party : RETURNING OFFICER BELGAUM PARLIMENTARY Stamp Duty Paid By : DHANANJAY RAJARAM PATIL Stamp Duty Amount(Rs.) : 20 * (Twenty only) Authors The Marfcandey Mahjla Mum I Purpl e Co-Op_Soc::.y Ud Kangrali K.H. SrJSga®* Kh00''-. C: O £ Please write cr type below this line ANNEXURE ADDITIONAL AFFIDAVIT TO BE SUBMITTED BY CANDIDATES Election to LOKSABHA (Name of the House), from BE LAGA VI Constituency. I, DHANANJAY RAJARAM PAUL Aged 42 years, Resident of At: Channewadi, Post: K. Nandgad, Tq: Khanapur, Dist Belagavi, a candidate at the above election, do solemnly affirm and state on oath as under. Statutory Alert: i The authenticity oi I’-is Stamp Ce'*.it«:ate should r>r veuleO at ‘w/av sfccikjstamp.eo'n' AnV tllMrawrcy i ■ itct.iils tin Hus Certificate and as av.t atOO on the eebsrte lence -s .1 inv.i ■ i ? In® (iimis al i Jiecking the epllmacy im lhi> uvus o' Iho cort licale. 3 in ca.se 01 any disciDpancy Dip nr. o infonn !">• Coiripetenl AulnoMy > ..2... (i) I have not been allotted govt, accommodation at any time during the period of last 10 years prior to the date of notification of the current election. OR (ii) I have been allotted govt, accommodation at X- (mention the address of the accommodation) during the period of last 10 years prior to the date of notification of the current election, and there are no arrears of any dues to be paid towards rent for the accommodation or any arrears to the agencies providing electricity, water and telephone at the said accommodation as on 2-4-2019 (the date should be the last date of the 3f<1 - month prior to the month in which the election is announced). — N (iii) No dues certificated" from the agencies concerned are attached hereto. —L VERIFICATION I, the deponent above named, do hereby verify and declare that the above statements are correct to the best of my knowledge, and no part of it is false. Verified at Belagavi this the 2nd Day of April 2019. No. of Corrections DtPONENT BEFORE- MB SWORtt ** n P ATlt. S.Coin., U.B. (SpL) M-ADVOCATE NOTARY t-2 An, 2019 Reg. At. SL. No