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Pon,, Ov.^+'* ?-Ia Trq, O", A1$,/Aotq S Po.Rue Ofrhe Proposer '.- N

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Pon,, Ov.^+'* ?-Ia Trq, O FORM 28 (sE rule 4) I NOMINATJON PAPFR Eh\hoa,",h. l.ti.trt^, A\)atbq ODISnA $aet E' STRIKI OFI PART I OR PART II BELOW WI{ICHE\ER IS NOT AIPLICABLE PART I (To be used by ceditlate set up by Gcosnised polilical party) I nomin,te as a cmdidate for cldion o rhc Llgislaiive Assmbu Aom rr'"..l&Q. .Srrna<la Assembrv..ncinucn.v .md'.,re! ndme PUTLOa---Cha.r]l,Q SdalD.. .r, r"r,.eers *srars ,)"*-Sn-ipa/E-.5&^ado...&UL )4a,hdAzu.S".aiA 'ri. p..,1r ,ddm... Sor.uo s ftu!] ,5.l;rrl)a -NAa, 6o,r1arn a{,alaa n" n,m. ,. en,e,ed s. No...35.7...in laa No...l ,3....oirte iiecronr rorr lor.t.a9.,,s.(l-lIacra..............Asenbty ny *.. i' namo-.chorcl,rr".da.xrre.dd ir is entered at sl. No.3a5..in pa.t No..1.73....oftleelcdomrrolforrhe..laq."^SLeEcde...........Assembryconshtuency. ( Pon,, ov.^+'* ?-ia trq, o", a1$,/aotq s po.rue ofrhe Proposer '.- n !, c d,darc ro- elecriol ro 'lc lcEi"lortre Asembly rrcn i{ nafre is e.lcred al Sl. \o '1PsnNo...... .. ofrtc.ecor.l'ollfor :\\ A"..mbly We declaie that we re elecion .f ihir Itc eec\,| rol. lor fih A-erbl) -orrirucl,y ^ ird'.rFo belo( alo !e,ppend our 'ierdMe"be}l. hbkeno,<ubnlb'ne.o.lnrol irariol' - \ Pmrt ul,r.ofih. Dromsen,nd rheir cicn,tures Elecib(Roll No ol Pronos( FuLl:rame sjcnruE l 6 l. 2. 3. 8 9. N B.- TheE snoudbe len electos ofthe constitumcy as prcposen. PARTIII I. t]re cadidare me.lioned in Pan L/Pan ll (Srrikc oul {hich k n.r apFlicabl.l assent to this nomination and hereby declaE th3! l!) Im acn'Tei oll1d.d dno nJre I or d.qnr.J rne c. /en\1rp otd I tor gi 5rare. (b)rhd I h,!ecomplekd..:r6 ...)em;f aaei [STRIKI OUT.OOR c(ii, Brl OwwH]rl l\ 'c lS\Ol \PP lrABll-l ,c' ' ) | dm rd up d, 'hn e'e...or t'\ r\eerlilb/'a1,Gb"i'. rhi-1 F re.oEn:ed Aksnt+34 \rare Par.) 'r .'i. s d e rr-d tar .Jhool '..ened l.' rhe dbo\e '1e party be alloned to me. (iD oEised pohical party/thal I anr conte$ine this election as indep6d6t candidhF.{Slikc out whicn is nor applicablc) and rhar the symbols I hale.hosen, iD order of prclc_i /d\ n\ 0are nd n)',rqnt slhea h!-!4G nin e h,!\ bt rn..n.. .r \pe' ou, abo\e ir L^9 L4i..L .. rnaineor,.e alsudge.. and /e) nd ro rhe beslbl m) Lnos'edte.no be ie: lar l q r ilrcd mr al.o o .qJal \d " 'o for beins chosen lo nll lne seat in the LeCislaiive Assemblyolrhis SraG . | 'unhe, de.hre Ltar mdmenF or r.el<al(tox foecy c*-e$!+I.n,, i se4red ''cis€s!€ or $e sbre of Odi ll a ..'aa'Y"o ..:-::_... .(dur,ir\4s.a.e H,##.5{ih"*tr;;:*k jilfu,yjr;."T:;H,i:i.."H.n D ..a5/.os./eoo /rL,-- c.- -cn--= -r*-ii-6,-n-s-i:i_d,iir@ Sienarure of Cedidate PART iIIA (l) whdh{fie mididde_ (i) h6 been conlicred_ ra)oJ ] otkoco\tuds sub-rclbr ll) tr iii:lil;;r,i:il'::' ;l';'ii;:i:ili:'^:i'i:1t' +*n"" '1" [T,::::.":#HXHfi ::i."tuG),o,.r,,"r r," r,u, u"- of$ermemed { Ac,u) &d or.r r.**;;;;;:"J;*;i;j ;;;;; .r,he counrsr berore Nh,ch tft aor."\ry"oriii"ii",r"ir", i ornot'u J''n ,)ir)ft4h1rc.mddd?' :T#dn sL-co\!-r"- .,, NA ---: ;/ * ola'"u^ *'"' I).;J';:"."".:1.:Jr,,'.,,0,'' r'' Ib''i'''e "r ;'i"'""""''''^ " "'' , il:'.:-:'::,.:" "' ";' er(!d.n,' .l)rdrNoi N+ F.nd.,"al,td "' L\ .,.,..nod o. .o,,,, ,\F. -n"!J9,r - :,,;:;.:,lil:";:: ;:l""TT::;:';''!'\' r\".,f.drcoru.hr'.m''-1 "",n.uo.-dn- .,.n.'.",n1i"'d-'l ";;::" - T.^ :;::;;:::;;,-:"""' lIi-;'"'"' ;y :l':: :::l;:":;::::::r:r1" :i:;iJ:r: : ' "'"'=Ji r- ",:':;.. ." *** . ;";."'.--." :' :'-.;"".:: "". ==***l**i*r1;::J.llT";::;i:b\ dlc (omr ",-. *' 0*' dRquahficd , * ntn" """t'0"9"" ", on .- w.F 'nsK J'{ ',,:l'"d'o_ ' '(' r'{d'co' .J* ' . \ *"0'u"" a^*, Swr:aAof da"y't*5az Kiu-' ""n' Dd.: a5/o3lolq ,.. .:""i"t.\;,^"",..,, -i:[:it' "'" T;i'i""i',lli1ll'l 3""1"i,-',j*t"i:;frS:ffijt'E$ D.,," z=1a\r,"'\ -^.a;;bt'ons'k0ei'Y,-"f:i,'.',ffn:""., PART V D..lrion of Reiumirg Odicer Acc.pting or Rejeting tte I nave exmined this .oniraiion papo in accorddce wi{l secdon 36 oI the Reprerqknon oflne People AcL la.' dd decd. s tollows: - PART !'T Receipr for Nomimrioo Papq lEd Nod.e of S.rutiny Go be nanded ovq to lhe p.Mn pGcnting lte Nonri.arioD Plper) Sdial No. of nomination papr................-..... Tle nonimtion paper of....................-.-.,-,..,.a candidate for €lecrio fron the..... ..........-....--.........Ar*nbly comtituency ws Celiveed to oe at my ofnce ar__...........(tou0 oo.,,,.,..-.............(dale) by 1ne ..ddidadprcposq. All noninari4 pap6 will be raken u! for $tutiny at ..-.....-.....(tou) or.....................{dlte) ir........................ ............(?loce). Et-{I , TEN 5qn RUPEES s.10 10 INDIA BEEORETHENOTARI PUBL]C, SURAD,\ CANIAM AFIIDAVIT TO BE III,ED BY THE CANDIDATE ALONCWITH NOMINATION ?APEII BEIORE THE RETURNING OFFICER FOR ELECIION TO ODISHA LEGISLATTVE ASSEMBLY (NAME OF THE HOUSE) FROM 129 SURADA AMMEBL1 CONSTITUENCY (NAMtr OF THE CON5TMUENCY) PART A I, SRI PURNA CHANDRA SWAIN "son/dtu6hrer/*U. oI SRI MAHADEV SWAIN, Age.l 46 yearr rcsi.leni of SARUA SAHi, SURADA N.A.C., IO,/P.S, : SURADA, DIST. : CANIA, -61103 ODISHd tuJ oJ.rJ dddr", r. .M.Lo. k . d e pt .oon. oo he,"b. 'Tmbon " "bove Nerun! arrirm md liate on oaL\ asrolotrs - I d c .ldaie set up by BrJU IANATA DAr" ODTSHA (rinane o1 drd potiticat lalb/)/[email protected] 8?s,nn:{ftte?sdenrfrrdrd,t€. ('rstrike out whichever is nor applicable) fti. ->12) My .ame is etuolled h 129 SURADA ASSEMBL1 CONSTITUENCY, ODISHA (Name oI the cotutitueuy and the Staie), at Seiial No 357 in Pa* No. 173 (3) My .ont .t telephon. nunbe(s) is/ aft 993n867s,9fiabas7s4 and my enait id (it dy) is [email protected] and my sGial mc.tia a.conn(E (iI ay) islme (i) Puna Chddn Srrain (Ia.cbo6r) (i, ,Nil Fot ,I,rn ol.. ,...,i"l.il* J, ' , ,1t r. _ 4"9 o#9'? ls's"'t07 eE -.7.f.5.... K u-fqq";q' s.v s.R'o' Bhanianagar (Gm'l (4) Dehils oI Peituent Accout Number (PAN) and sbtus oI litin* of rncore Tax retuin a.r\tli I /_.*7'"** i\ PA '9 tB,lt. rRd ccQPs274rP *#n tsrrrr y'C. s^**--* w{9 CQUPSIISI]I L Nil NiI NN Nil 5, NN Nil MI (s) Pendingoiffalcases n\ | d6 li."'}dl thqb \nope. dDg,'iJrw .6p J8zr.ne. \I nit ttr\nltltrrrtttttE,? | ohr \,..n*p dagrBn\!),? ;nd,h oad tunp NOT APPUCABLE aB|,Bt itt htdtilE (ii) tElaat (ii) fte f.Iowing criminal .ases are pending agaitur me i (U fiere are pmding cimiml cases agaitur rhe candidare, fien tick this dteftatiwe an.l sore oil rlrematire (r) abov., and give detaG ot an pendins rrR No. with nane and addres or Polie siation Case No viil] Nahe or the G) se.honG) of concehed A.ts/codes involved kre N. aJ ur s{kbl, e4. sedior wnedE chare€s have ben -13 frme,r (meftion ]Ts or i0 ff answer a8aind (.) rbove a YIs, then Srve rhe dtu on ,hich chr36 i.ere G) whethcr any APPeal/ b@n filad agairei rhe Procedinss arrtrriD, Yas (5) caesolconvichon , tl rL - (i) I d(larc !hat, I have not beon .onvicted for Ark tuk nltermtue, il E ndidnb las nt bd .o ricted ntu1 tutit NoT i'! r ats\ APPLICABLE rgnnd nkenlnhle (ii) Md|) t have b@n convicted lor the oI /s (|ftutdndidatctnstu canlnkd,tha n&nnsnlk nnun n s.oft afaltettutiry (t) nbat, ntu|Ei@ d.tn 5fi it Toble beLo ) xy,eNa. NN NN 4D^ t ry Nil Nit Nit G] NN Nil (.1) Nit Nil G) Nil Nit Nit (0 Nil Nil (c) Nil Nil (h) Nil Nit (6A) I have given tuI and uP tGdate information to ny political part, about all pending crminal .ases agajnst me and alout ail cases oI .onvjction s Alven in p agraPns (5) ard (6). IN [Cnndidntus to tula this ]ten ls at applic.'Lne sllatld.karlv tunE NOT APPLICABLE []=: t'IEwoIE T/IIES IN 5(,) o/d 6 iiii.--r-,Is,a[; { t- aAlDt??', I ' D. tou' tnrltllx?nPro Do trrdrytbt! , 2. Details ta}! iwn epnnbl! kr e&.nP detdifrtont@Latnso\ntsten hitu t. I Detuih 4loin W fi d'ttv .htonal%i t adzL i e., a ttust .r* ta b ltst i. Snpn 'Enrion?'i nndbo.Lmnts ir tE atld nJ drt s lar E ottet dvs 4 AdAina ol s|@t nybndde.iilreq nrd. jn.onqlirna is sibte nrypluitlgt ih aJdan'hte s Ptnecowt\ 5. cintlid.te re4n fu 'atid idsnnt i'1w.P.tC) Na.536 of2011. Fd lP.r or. ikJ.F .4'v L ....- ..l,- ^ (.4i__. r^r^FYsoRAoa {GM.,ill i llr q (7t fl@t I gif tld bttor, u@ d.tnik aJ lp nsers On@ble nntl ihurahbte ek ) af vyL t1\ .tails ol nubltastPb: A$ets in joint nam indicaring rhe e*ent ot joinr own€rship $iI arso have ro be .N. PATR mr{ In r6p of d"po.n br'e,mmr.
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