vt"tl2 ( FORM 2B (sccrole4) NOMINATION IAPER the Legis lativ. Ass e,iblr' ol. 4] 5r|4.,....(.tare)
I STRIKE OFF PART I OR PART II BELOW WHICHEVER IS NOT APPLICABLE PART !
(To be used by candidate set up by rccos sed politic.l partv) I nonimt€ $ a candidate for elcction lo fie Lesislative Assmblv fton lhe.7.A.L(A .r$aAu!...Assenbly Con{ilucncv. CrndidarCs nane... .ld$Tr.sl.tl d4{..Ji.Lrr:4...... Fatbeivmodels/husbdds nanetaiE.r..ls:!€i.nnclautdllis posbl ad.lrcss ea:t4r-"pril My nme is ..IUAA.035,JA$1...... and il is ot€rcd al Sl No .ll.61.. i! Pan No... 55:....,of lhe clccloFl rcll ftr ltE.7l.-l Signature oflhe Popos YP,F we herby noninatc ss cmdida{e for election lo the Legisl.live AseDblv lion rh€...... AssenblyConsduency candidate\ nanc...... )A...... '''..- - --'''.-X Fathers/morheis'husbmd's .. ..-.{ ..HB poial.dd,es k ...... 1 ... 4 H\ name h enereJ ar sl No..-.f...... inPadNo.....'^.....oflheclccloFlrollfor" ...... Assenblv. I 0 : . We declare rhar wc are elecloB of thG /X Assembly conslitnency dd ou nmes {e chrered id for this Asscmbly constitucncy as indicoted below loten ot subscribins ro this noninalion: _ rrecor n,rrr,lo ot rro;i*i 2 l. 2. 3 5. 8. N B.- fherc ",oLtd d" rn d.. ua;;;;;;;;;;;;;;; _n,"n . no, .po ," ",.rr;i_li'J,.''. ",, cdb,e, a{en, ,o " "";ll;;i,f:*'T;l'Ti r,l Ie,^dih of.rd'1nd tu\e ro! d.qu,,ed rhe \rri/m.hrp o, ey ro, an Sr,re. r0r rhar thave comptr'ed...... )edsofaEe, ISTtuKE OUT c(i) OR c(ii) BELOW WHTCHEVERIS NOT APpLICABLEI n) /il - .T up Jr (teclon er l1.. b\ rhe...... pny. w1,ch rs recognFed Nd P"r) \J]rl,a-, n.. qne ^.al - ald rha he sya6o. rcsens to, Lhc pany be allored lo me "bo\e OR p'(crion rhe - by __ ...... pry. qhi.1 F d Rgrnneo_] 11 l:' rtwogn{d".hi. poLrtat l"n D"1J .har I d contesrng -hi. ete.nol s ,l .ldeoc.d.nt.andidaro rSr L" our qt-trh gc n nor appt.!able,,nd |ndr rflbot. I hrve choser, ordcrufprcrerencc. rre._ 'n ror ."lik; ;; (N6lrrlid;";;;,ll;',;;,'#" ;,#'l;""T;;.* :;;,;;;; -bo.c 4 .. rlnco,rhe.d,dxaBrJ ma "' dbql' ned ifi:lj:'.ij'Ji iti:".5"1:;ilj$!ti:l it^,ll.lti Tf;l,j,so ' I fLr F, !e. i . .tTr Jmd heribp.of.fe ... !... .rcalkhbewhrhhdnhedltcd "cereribco.Lhcs'ieo ....> ... ",".,r,;b. .2/ .... ,dea,mrt,,.skk ( lso declde thal l have nor been. &d shall not be noninatd * a cddidale at the p$ent go@l electiodlh€ by€-€l€clioB bcing held simultanously, to the trgislative Assedbly ODl.lltr of(State) nom noe dan lqo Assenbly conslitucncEs. 6'^t 4 s*4 Ja't'uf a Dak..4'(. 3.i:rsq Srgtum ofrddidale f PARTIIIA Go be filled by rhe cand'ddO (l ) wlEthd ihe candidalr (i) b$ bed conlhled $dion( o' G)oidyor.n\(tuido "ub ) (b) for conrrsvention or any law sp4ified in sub sction (2) ofseclion 8 oflhe Represertation ofthe People Act,l95l {43 of l95l)i or (ii) ha b*n conviced for a.y oth( offcncc(t for which be h6 been renrnced o impr .onmPnr 'b' a o ) cds or morc. Iflhe mswer is "Yel,lhe candidare shlll funnh the followinginfomrlon: (ilC!'efir{ infomdtion repod Nu Nos .< (ii) Police slarionG). ...x...... Dhtric(t....:.$...... stat€G)...... (iii) sationG) of rhe concemed Ac(t and bnef descnpdoo of the ofience(9 for which he bs been convicleq ...... 4. . - DareG) of corvicrionG)...... X...... (v) Counc)shich convnkd lhc.rdidJre . . . (!i) Punilne.lG) imposed [indicate pe od of imprisonnentG) d (b) Nat@ ofoide(t pascd.... (2) wllether d. cmdidrre is holding sny offrce ofprolit udcr thc Govmnc of India or shre Govmenr? . .... (Y*No) .ll\e..debihofrhcofl.cel'eld --. --.^--. .. (3) Whclhe! the cadidate hd b,rn deltred insolvent by an] Coun?...... (Y64'ro) 'lfY!\, hashcbendi{h,'seJ lion iNolvln\y ,x (4) whdher the cmdid.re n undq arlesimce or adhecnce ro my forci8, counrr/ 2X.. (\+:No) Jr\ei gtredebil...... ) (5) Whethd rhc cmdid{e hqs ben disqualilicd undq $ciion 8A of the sid Act by an oidd of rhc PHidenr?.'^ .. (\+!No) lfYcs,thcleriodlorwhichdisqualincd...... , . (6) whether rhe cmdldat was dhmissed for .onprid ot for dd.yalry Nhile holdin8 ofica u fl fie Govemmcnr oflndi! or rhe Govenmol ofmy Sra!!'?...ix. (YaNo) JlYcs. lhe&r. olsnchdishi$.1. ....X...... (7)wherher thccandidarchas my subsisrins .onhdG) wrh thcCovemne eithcri.individual capacity or by tnsl or Dadnc6hip in which fie cDdidrte hrs a sharc lor sut'ply ormy goods orh .o\cmncro' -e\+-'i 1or n\' h"'Lo."mm-dr2t k "o'krLndcrs ^d lf Ycs, withvhich Covcmncnr and derrils of subsisringcmte(t.. .,< ... (3) whdher the cmdidare is a mnaging agcnr. or nmaE.r or Seicrary olaty compuy or Corpoialon (olhs than a coopcnrive so.icry) in dF capiial of shich the CdhV Govcnn'cd or sbre Govemcnr h6 not les thm twenty fiw p*e shrc?.. .x . (v.sbo lf Yes. wnh which Govchhcnr and thc dctlik rh{eot.... A (9) wllcrhci thc caDd idare has been disqua lificd by rhc CoDmhsion nndcr se rion | 0A of lhc eid -If yes,thedrteofdisqualifi ton. y €g,ttffi'f"^u{' 24.7- t1 (ro be trbn by $c Rddn'ir8 omet Serial No. of non jnltion papcr.... eN{.|.c - ,,?^ This nominadon was d€l dscdtdme d my oma d \+?>(r'dw) * rhe ca.didalc/poposer (N ane ). D.E. d4d\\ €lqa et g6qt og lc|ae q€d|eo lefio ra* (c)/e9q(Q)l s, ...... s-5.6!9....e€r....er4fi.J...._,...,,,,,.._....,,,,,,_...., elelqel a 'i 6n|cQEI sadr66Gl..- .oc ane qoo qcerfie ecqeos€ m'o ffiffiffi cge 60 iiasnA{ q6€e cnee a'fti|eo6o aqo g .{e qt*{tqq 8{E u Et oqe cnee e !eo€r9 qq{iP e66 | S.4..n2 s*n (gralco q|6o 0 -| qr9,e aee€o en) j, or?r lQo6otar oE c ma! | aar roa) o...... NLF.:...... o€e....,...... p1...... er66o .. ...'?1..:..?*.....f ll. o|6estsnar.'s,rsra....F.€:.an"gc1....1. eqo, Tl:.lllafl "n-- :.... mlqqs6a a{ec en6e doa ?ar6ot/q6{6$ et€6o q6a ea|o^,, ,! -&1-'1 e'$:iffs#tT#"o) lt&m6 Fo 4s.€mbly Co8rfiu.ncy ofioreiQvn oorsHe Or' t AIFIDA\'IT TO BE IILED BY TTIE CANDTDATE AI,oNCWT I NOMINATION PAPER EEFORE TIIE RETURNINC OTFICER FOR ELECTTON 10 ODISHA LECISLATI!'E ASSEMBLE IROM -7G KANTAIANJI ql tr CONSTITTJENC Y. kirl !4BTA !'son/of g- l, SANTOSE S|]\GE SALUJA, LATE INDER SING SEALUJA, Agc j9 y@ rAidenl of aT- KANTATTANT, p.o/p.s.,l({NTABANJT! DISTRTqI- ronncn, ooriaA t, PIN- 7670J9. a ,r he abole tr I "rndrd.'e etdrio-. do nerb) stennty amm ond 5bk on oa r 6 ? (l) I d a qndidde sl up by INDIAN NATIONAI CONCRESS t My name is enrclled i2) in 70- KANIABANI OF ODISqA STATE or Seial No.992 I in Pat No.55 OI (ANTABANJI contofl qt-94j7063316 .d I lJ). .M) tclepl-one ndmben{, i! dd mJ emait n s{dluja60@smait,com dd frl :ociat n eora aMrnL k (i) whahaap No. t43?068846 €-€*, ta s-n 1^,^E s4> <.!ls_)4r-2.," ,HiNr(APLa(fixF I !TAMPvENDTq (. (4) D.tails of Pe.nirent Accoutrt NuDbcr (?Al9 Md stltus offiling orlncomeid rclurn: Sl,Nu. rhoM i. Incone Td Retum (in Rup*t for :he l6t five Fimncial Yds conplet€d (sonll'l SANTOSH SINGH r017-2018 (i) z01l-r4 - Rs.4,68,r 00/- SALUJA (SELF) iD 2014-15 RS,4,98,536/. iiD tol5-t6 - Rs,6,7o,281/- (iv) 2016-r? - Rs,8,4s,749/- (v) 201?-r8-Rs.6,81;9r/- 2. RABINDAR XAUR I01?-2014 (i) 2013-14 -RS.3,01,654t iD 2014-15-RS.r,59,707t iiD 2015-r6 - RS.1,55,766l- t016-t1 - R5,2,91$12t- 201?-t8-RS.3;7,122l- 3. \OT NOT (D NOT AIILICAI}LE A}PLICABLE APPLICABL (iD \OT APILICABLD E iiD \OT APPLICABLE \OT ATTLICABLE NOT '\PPLICADLE NOT AP?LICABLE (iD NOT APPLICABLE iiD NOT APPLICADLE tiv) NOT APPLICABLE t4 NOT APPLIC,\BLD 7r;} ;) :'M9 1-",,t S q,t'lo , -,.i,1 a_ 3,j,tq M 8tqLfufr W)'l*o NO)T PUFllc' iAlf \B AN r-767039 foUoYitrg crininrl ca36 rrd (CASE NO. D Table (a) FIR No. with nde ed addre$ of Rl.RNo- 166 of201l, K!trrabanji P.s, AVI.OJP,S.- K!trrabarji , DbrBrhngir Odish, Casc No. with nme of the coun C.R. ClseNo-362 of20U G) S€clios of concened ActVCod6 S ecriia-r 47,4s2 263 22s ;07, involved Give no. of lhe secdon, 294,323,1 14s06,149,341, 353, or I. P.C rerd e.g- Seclion. .. . -.of IPC, €tc-). siih Sec.7 ofCribiDd Lxw lnenihentAct (d) Brief descriprion of offence Rioring, tlouse-tresFss, obstlciion lo thc hwful rppr€b€nsion of rny t.6o(' rilenl,l to nurdcr, obsc.n. lr ngu agc, volurtarily causitrs bun, abstDent of any olIem€, Cribitr,l irrinid,tion, wrcngful assenbly, rslnih.d Whelher cheges hav€ been ftm€d NO Ifmswe! qainst (€) abov€ is rES, ,then sivc thc dare onshichchdecs \"r,'.a NOT ATPLICA}LE any AppqYApplicadon for rl {c)'?e i I fi&lher 49sion has been filcd asainn rhc NO (M€nrion YES or NO) ,et.lt/r 96ceedincs |-t ") rl <_"*._r s.-{i <*9f ly- ( itJV\ary4l rB!lLtiac ?[0!3 (5) ?edire crinioal crs.s (ii) I declare thar thc fotlowing crininll cas*,r. penlirg.gaimt nc: (casE No.2) Table IIR No. wilh nme tud address nl.n- No,0?7, K.ltrbrnji of police srarion co.cemed, l('rr!banji, Dist" Brtrngir, o) Cde No. wilh nme of lhe .oud G,R, C8.No-2s4 oI2009. Setions olcon€me! Acd s.crioD-1s3J23.194,452, ot l.P.c Codes involv€d (give no. ofrhe section, e.C. Sedion...... of IPC, Driel descriprion of oEence Asaur or uF otCrinibrt forc. to dcteru pubtjc senrnt from ilischarg. ot bis dutJ. votutrtarity cau!inghurl.ObscenerrrBuage.Housercprs, Wh€$er charges hdve been timed (nenrion YES oi NO) YES (D Ifmswe. agai.st (e) abov€ is YES, then give the dale on which NOT lOtOWl{ f any Appeal/Application sion has 6@n filed againsl :eedings (Mendon YES oi NO /* / r) ,/r) i\ 11t.. C.-n\ s--n s*,X9 2\-z-tq ;\\l Qtofoffa ffiWoyt" NCTA Y PUBLIC. 1N,ir.?ii7ca9 (s) P€dins crioinll cases (ii) I del!rc that thc followiry criniml cascs rro pcndiry asainst D€: (CASE NO.3) Table G) FIR No. eith nme dd aditess F,I.R, No-076, Kantabrnji P.S., ALIP,O,/P,S- of police sbdon concemed. Karrab!trji, Dist- B,l,ngir,Odish!. (b) Cde No wiu hme of Uc @un G,R, CascNo-162 of 2009, J.M,F.C., Secdon-341,353,29,1.186,50634 I.P,C.nd ? of Aclvcodes involved Give no Crininrl Law am.ndmctrt Act, Section...... of IPC. etc.). (d) Brieides ptionolofaence wrongrully rstnining, Asslult or usc of Cnminll forcc to dctcr a pubtc senanr lrob discharse of[is duty, Using Obscere L.ngulge, CriDinal irtiDidatiotr, cobbon inreDdon. Whelher cbeses have b€en nmed (mention YEs or No) NO (i Ifmsweragai.st (c) above is YES. then Cive the dale oh NOTAP}LICABLE which chdces werc fimed App.auApplhatio. for revision h6 been liled agaiist lhe 4".silff:i"*"- - NO 't\ \- \ ';/;. d^^-t s -{l I a-La".r- ^ 2s.3- u t1 rrC \ t./;t\\) tufufnftftitNaY\ 'NOTARY PUFIIG "A:li,4t;trJl-767039 (5) Pcndins c.ininal cascs (ii) I dc.l$e thri ihe following cnhin!' cascs lre pctrdiq againsr me: (cAsE NO.4) Table FIR No. wi$ n@e dd lddess of nI.R No-07s, K,nrrb,nji P,S, A(/P,O./P,S- l<.ntrbmji, Disr- B,l.ngir Odisba (b) Cae No, with nde of tne coun C. R. Crse No- 161of2009, J.M.F,C, Sectio.s of con€ined Acls/Codes Sccrion-147J94,127,Jt2,506J42,',19 or l.f .C nrvolv€d (8iv€ no. ofthe sectioh, e.g. Setion.... .of lPC,erc.). Brief de*iprion oroEence Rioting, ObscetreLangu.g€Mischief- Robbcryrcrinin.l inribidliion, -wronsfully confitriq ary penon, unlawful 4s.nbly, .very other member of snch sscnhty shall be G) Wneth$ chtuges havc bcen tmed NO (0 lfdsw*acainsr (c) abovc is YEs, lhen give lbe date on wbich chdses NOT ALPPLICABLE Gll /\. :'\A ^ NO IQtr 'ae [-,1 , S- ^,r.r S *n I D )t \-t1 flb- 6v."'^1 C '/nu' -,4$l*X#9.1 :;tj : ,N.,r_762039 (5) ?ending clininal cas.s (ii) I dechrc tb.t tbs folloting cribiDalcases are pctrdi4 aglinsl me: cAsENO.s Table FIR No. wih nme dd add@ss F.I.R. No,8/ 2009, DrlgoDu.da P.S, ArP.O/P.s.- of police stadon concemed. Erngonund., Disr- Balansir Odisht, case No. wirh nde of the coun G.F. C.s€ No-20 of2009 Secrions of concemed AclV S.ction-143,353p83r94, U 4,149, of LP,C ttrd 7of Codes involved (sive no, of the Cnni.d L.w lnendnent Acr. section, e.g. Section...... of IPC, Bnef desciplion of ofence Bcing mcnber or rn rnlNful a$enbly, Assault or *. of Crininsl forc€ ro dctcr a public senall Iron dischrrgc of hi! duty, Obsc€tr€ bnguas€, Joining h whetne! chdses have been fnm€d (nention YEs ol NO) NO (f) Ifmswer asain$ (e) abole h .xES, then give tne dale on -{hjch cha$s wer limed NOTAP?LICABLE d6 {'t l{iA {.,, NO il ..','. S ^\hJ l.\1 e 4^+ 2s- - j- )9 (s) Petrding crininal caset (ii) I declue thdt thc followirg oininal cascs ar€ p€nding asaiNr b€: (CASE NO,6) Table FIR No. wilh hme dd address of F.LR, No.3/2009, Truekcl. P.S. AUP,O./P.S.- Turek€b , DisG Balatrgi Odish!, CaeNo. wfi nme or the court G.R. CaseNo- 18 of 2009 Sectionsof concemed Acli/Codes Sedon- 500,506,509,14334, of I.P,C iftolved kie no. oflhe sedion, e.s. secrion...... of rPc. etc.). (d) Brief descrptonoloflere Criminxl intinidarion, Uttcrins .ny yord intended to insull a wonln, Being b€nbc. of an uDl,yful assenbly, conmotr irtenrion. Vnether chdg€s have been hamed NO (t) Ifflsw€r asainsr (e) above is YDs, then Cive the dale on which cbdges NOT APPLICASLE :1sL) | ll9elF{ fl y App€al/A!pt(arion fFn+ie\n hN ban fikd asainst ."- rfididfaed, nss rMcnrion YEs ol NO tro)r.] ,- l <-^U; < -"1 9 q-tr ' A^"i (s) Pending .rininrl cascs (ii) I dcclare that 1[€ followitrg crinin,l.!sa fc pcndingag.insr ne: (cAsENO,?) Table FIR No. with nmc md ad.less of police nI.R. Nol65 of 2007, KnIrb,nji P.S, Ai/P.O./P,S- Katrrabatrji, CaseNo. wilh nme of thc coun G.R ClscNo-369 of2007 G) Setions ofconcemed Acts/ Codes involved (sive no. ofthc section,e.g, Section...... of lPC, erc.). Bnef descriplion of offence Usidg Obsc.nc lNnAuaae, Vhether chases have be€n frmed NO (0& If tuswd as.inst (e) above is YEs. then givethe dale on which cheges weE iTt NOTAPTLICABLE ii,;ii ;i G) ;Whcq1* my AppeatApplicarion for rlvi3i{n hs been filed asainst the ')"' \ 'dnleldinss (Medion YEs orNo) NO '*i -ilffi L-^l;t <-t1' s alto_r- (i) I d*lrre that I have nor been conricted for ary criminll ofrcnce<{ (Tick tbis rftc..iriv€, if tlc cfdidrte h$ not becn convict€d .nd rvritc NOT APPLICABLE agninsr !ltcrnrtivc (ii) belorr) oR (ii) I hrve been convi.ted ror th€ oflenc.s ncnlio.ed belos: NOT IPPLICABLE G) s{rioB ot^cdcodes itrvolvedciv. no of th.s{rio\e.gssriotr...... Bicr dsoiprioo olorTene ror DnB ot orJs5 orloivi('ion () nredrgaii$ convi.'ionoild(Menriotr fai$d ro G) .bov. r YES , silc lbiG hd pnsN nrtus ofrppetl 4=:i .,.. t, '.i f., toor ' "\ lnd upro-darc information lo ny '.0, ainst nc d aboul aU caes of conv \IOT A}PLIC BLE IN VTEW OF ENTRIES IN 5(i) 'Nd 3: --n r -\ .'+ €.'Lle I 2e_3_tl W, (t) Thal I eive herein below the deuih ofthe ssetl (novable fld idnovablc clc) of nysell dY spouse md all depcndents: A. Delails of BoYrble rssets : nnrosb SitrBb Stldj, (Selt) Pi,3,00,000/- iD 5.B.1, B[ub!ncs{!r, A/C.10872249631, R3.87,313r A/c,11263590.tr8, Rs.6,13357t- Deposils md all other lypes of (I-D.R) includingsvins S.B.I, Bhubatrcswar, deposils Rs..1,63,336/- u,B.I.T.D-R tu.39!013/- accounls). DcPosits *i$ UBl, Bhnbrne$var, U,D.F.C., BhubrneNlr A/c.No-l5030r6101352, Cotutlnies dd Rs,30,25,?9,U- / H.D.F.C,Bhubane$ur, F.D Coopcrative societies and tbe mounr i. each such deposil ,c.No1126359.1593, Rs,14'09Jt4l A,7c.1846010000019, Rs.l99?J31r Sah.H Eous'ng Bond. Rs,.14,000/- uBI, Kanrabanji (T.D.R) A/c, 18.16100000019, Ri.l,5r901/- pr.B.r., Kmrab,nji, (T.D.R) F./.. No. 1846100008907, Fs.134,019/- h,/c. No,007053001352, ns. 1.s33881 iiD Deuils of invesldenl in Retiancc Ictrol chenic.l Rs,4,000^ Ambtrj! C€n€nt 100 Shlrc Bonds, Debenlurevshes dd.d unils in co.i;;i".^l"rul Funds SFFR{d'hem@d. -lC Policy No.69075s747' &,1' !7005196502, R!.4,0?.600/- :,;:, LIC Policy No,s93t62076, Pi.s0roqo/' -, I ..rn$\ i 'hffiitNaJa\ ;; r;ffiIffi, L^o, *€\ 9<-l4" IL !t Pe6onal losvadvance I liven lo dv pe^on or ;ntily includin8 fim, conpany, Tdsl etc snd joder reccivabl6 rrom debto6 and ihe anounl !il M-d vehicletAicdns/ Mduti Van No.OR-15_F 3443, Yachlvships (Dctails ol tu.s0,000/-! Vear or Purchrse Make, €aistdiion nunber. etc. year of Purchase and Maruti Bcleno No.OD-02-AR-8208 viD 60 s. c;ld;;.rht R.i,so ' riiD \IL NIL Rs.22J537sl- Ll r..^n"L S-/1 la$ C I r/-tt\ a,nnl[(,,#,rtq'k, NOTARY PUBLIC (ANTABAi'JI?67039 B. DeMik of lmnovable A3!ers: Nore: I Propefiies in joint omership indistins lhe 4tenl ofjoinl oMeship will slso have to Norq 2. Each lmd or buildins or aparmenl should be meniioned sepmtelv in tiis fomsl n1'5ffiffii".lti /:t,/t. fn t:i' wi.q+s v:;r $*/4 Yr \ .i +.C.,* , YanrlW#Witan S---.n-i :-r1 3 Ye:" :,!o$"r^iYg:]:." 29, 3 -tq 6i-ryK- '/-:' \; -\.t'i: (il) -rl#14{i;I,Jii ar't s -(l s h5. NOIl1-l^iriieroag />Pi-n\ S^a SA sd'1t Ztt- 3 tq 0 4l wr""- 'kofttt NOTARY PUP,UC (Nole: Ple6e eive separate debils of nde ofbEnk. instilution, e.tity or idividtral and t. Sclt Loln or du6 to qousing t an fron s,B.I., Bhubmes$r, Rs,4,1r,773.00 !!!i!!t!pd$ A/c,1346300500019, R..3,55, | 68/ Nanc of Bank or FinMcial Instlution, tlousing Lorn from S.E.I., odsrandinei Bhubln6war. Rs.4,19J73.00 NIL NIL NIL NIL 0i,2,09,887/- !*+! s*fl s4,t1. 2t-3 -11 (hot'lt -NOTARY PUFUG (ANTABANJI-767039 (A)HA $e Depon been in occupalion of DS \r acconmodatio. provided by the Covemnent at oy tioe during fi€ lrsl ten yq6 b€forc the date of nodndion ofth€ curenl electio. ? (B) Ir 4sw$ to (A) above is YES, ln following declanlion nay b€ fumhhed ndely: (i) The add6s of ihe Govemncnt qudnes No.s, Type-VIR, Unit-VI, Bhubanesw.r. (v!crI.d on 13-2-201s) (ii) There h no dues payable in respect of dove Covenn€nt acconmo (d) lelephone cha.ges 13-2-201s. fthe dlte should be the lst dae oa rhe lhid nonlh prior to the month i. which lhe el€ction is notified or Eny dot€ Nore- 'No Dues CeniffcaG' nom rhe agenci6 con@ded in respel of rcnt, electricity charges, water charges and telephone chdg€s for lhe lbove Govemne acemmodar'on should be *-"91 s--51 3 -tn, 4=z-r9T 4tu / /at'tA$ ?ra ffiwrNqaL NOTARY PUPI.Ig qr{ra '< e ANJI'767039 o ependen!2 Dcpcndcn!3 .iv) NIL NIL NIL NIL IL NIL CSTdues NIL NIL \IL NIL IL NIL NIL NIL NIL \IL IL IL NIL NIL NIL \[ \IL NTL viii) NIL NIL NIL \IL IL l'{IL wherher ey other I NTL NIL IIL IL NIL liabilities arc in dhpure. ilso. menlion the anount involvcd and lhe authority before which it Dchils of prcfesioD or occupation: (9A) Derails of sou*G) of i.ome: (a) Self -Asricullur€house r€ntandpension (b) Spouse HandloDns.house rent, soJ.eo''n.otrc.ii"n).ordeoendenB.. . \IL...... { l Dlbho.s .itl arp.op,i"r" Cou"mnert and any public compar $\ d{|iil. d -o r.n h {kred b) Ihe cJldidt- . . NlL...... (brdrrl}ko'.o rid.',cnrcd inb b) spou.e .. NIL .. _{o) Calaih of conracts cnlered inlo bydependenls..,.,.,..NIL ,4a)'delaih o i contacrs €ntered into by Hindu Undivided Famil cddidatc or spouse or dependen$ hale interest -...... NIL ,"'d""k",fi4'.., en.eFd inro b) PJrne ,' ip Fim. ir \hict kro'drc o, A ll 'o spouse or dependents aE partne6 ...... NIL rn debrls of con'mcF. e.'erd i o b) pr:\ak.ompanie" qhi.l- cdndidsre or 'n spouse ordependenrs have share...... ML (10) My€ducrriond qulifietion is as under: Pass€d Dachelor in Conmerce Degr.e fron Indim Gandhi Nalioral Oper U.ives'ty (IGNOli) in rheyar-June 2010 lnd Prs.d Cenificate in disasrer n.nlg.ncnr trcm tndir! Gandhi Nliionrl open Uniycrsity (ICNOU) in rbe yer-Jtrnc2007. (Gi!e details of hich€sl School / Unive6ny education mentionins ihe ftrlt lom of fte cenificat, diplomt de8ree 6uM, noe oflhe Scbool /ColleSe/ U.ive$ny Md the year in whicn lbe ourse w.s cofrpleted.) g (,zt-v- ^^F-,t S-.n 2..3,11 -,+- -&- iir",'-" NO'IARY PUFUC r{ANTAEAN.rt,767039 I t PART-B (l l).\D\ tRAcT oT f Hf Dl TAll s Glvf\ l\ ( I' To ( 10, of PAR l-A: s^Nross srNcH s^LUr^, soi o PosrP.S- K^Nr^B^NJrj Dii IJALANCII' ODISH^ PIN.767039 prnytrhjch$i|pdt oididr. (od$rhe wrire .hdeFnden.) i-, t, \ n I -.s s.-l S- t.,, 1Mfr 413 B T Prat'L[t 'l.""#".I.Y#3.' Rs.5,65,055 Rs,2,09,88% Lisb irEs Lhdfe und.rd rpuLe M Hjcr,en .duarioi rr quilific4ion: Puea rrcteror ir conmcrce..eneGn ODen Unircniry 0cNolt) in rhe y4r- JuD. 2010 rtrd Pss.d cer nsft rmn hdiru G,odhi Nf,rionll Oper UniycEity (lcNOID in rhe yer- Juft I 9a \{r'4 J.-r1 5aLz1, 4-3 -t^ VA))**, NOTARY PUFLIC' 'iANTAB^N.Jl-zSZOag YEIUI:ICATION I, thc delorcni, abovc nnmed,no hercby verify tud decte that the cohrents ofthis alfidavn e ffi::il::x":jJ:*:"fJ;:[",#]'#;#:"1*:"1;Tj - p"n of i, is fr;;;;;;; !%i:'"fflffiT;T;i::'orpendinsoeaeairstneorherrhethosmen'1ionedinirens /b\ I my .po6e. o. mJ depmdenA do nor har'e e) Ner or Iiabitir) . orh- rhtu Lho* 7 r enrior@ In iierN !d 8 of Pfi A ed iren. 8. o Md .O oipd B atu\c_ ve fied { KANTABANJI lhk rh. 25'i dry of Mlrch, 2019. cd rc,rprkrized by d.pomd.ied Nr od npr,in.d,h. -,-L.r Lhn,md.ir i" lsmerc m ihis befor ne. I jdtr'it ,he d@io. &eu-,P'.+aIL* Bi\hnu Prusrd Shrrma 25.? \" S-^^,r,--.1 J.-vl s 4l?- Advocrre Ittomr\IT r4-:-rg f AFIIDAVTT sAl,ura, sm :,*:9:tl --sll.-" of LArE. TNDER srNcF sAl,urA, residcnr of AT- ll^Il"li": j..,f.. Kn\lAaANJr. Din-BAj-AAGTL oorsno. u".ng ia"n,in.j q -''"rerriv affn bero* i;l;i'iiiti;.^"'"'''' 'hh "I'|jdavi' T ehr.;. Qra ff KA\1ABAF'Jt-767039 i-l t