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4A I" /> og/or. t.2.+..< - X-)<P-, bet^) / >,rta / 2a DL. x.o. rc FORM 28 \t (See mle 4) NOMINATION PAPEI{ ction lo lhe Lcgislatite Assemhly of.4$. 4"rq ':.: ' .'1 i {'' t>a i.- STRIKF] OFF PART 1OR PART II BELOW WHICHEVER IS NOT APPLICABLE PART I (To be used by candidate set up by recognised political parq/) I nominate as a candidate for election to the Legislative Assembly ftom tl:e..L,b, 'P.a.:. 15.' name is entered at sl. io..9S7..i,punN./{(..tff"a*toratrorttiQA,.8xbirr.(fnad.a./l...^sserrrbtv consEntencv.-"rr'.l,ri ;. B..q.SudeA ...84a;.................and it is entered at sl. No.r-{r-..h Pa11 No..l.0-.?-....ortr,. ectorat rcl:for the.0 6r.Bna7. nE na4a "t t -r.:t::*, ,- l:r"io:l',, //a q, t /q, tcl- ,l Date .(*....1. lf ./ cl c / | Signatue of the Proposer PAR'T II Wc hereby nomirale as candidate for'\ election to the l,egislative Asscmbly liom the...............................-..........Assernbly Constit\ency. Candidate's name...........................................\ .Father's/mother's/husband's narne..,,....,...,.......,........................,...His postal ad, ...-.......His name is entered at SI. No...........-..-.inParrNo...--...........ofthcclcctolal roll 1bt...........-................................ .Assembly q constituencv. o 1 I We declare that we are electors of this Assembly comtituency and our rlames are entered in the electoral roll for this Assembly constituency as indicated belou, and we append our siguatwes below itr tokel ofsubssribiag to this nominatiotr: - the Droposers and their S1.no. Elector Roll No. o\Proposer Full Name Sigllature Date Part No. of S.No. in that palt Electoral Roll 1 2 3\ 1 5 6 l. N.B.- There should be ten electors ofthe constitueocy as proposers. I, the candidate mentioned in part rl*IT,1t",* out which is not applicabte) assent to lhis nominarion and hereby declare thaF (a)Tamaciti,.enoflndiaandhavenolacqutredtheciliTenshipor cnr lorergn Srare: {bl lhat I have complered.....91.f-....1ear. olage. [STRIIG OUT C(i) OR C(ii) BELO\V \VHICHEVER IS NOT APPLICABLE] (c) (i) I am sgr up ar this election by the ..Cf.L.........pany, *,hich is recognised Nationyl Pafiy/Srate Party in this Srare and that the slmbol resened for the above pan! be alloled to me OR (ii) I am set up at this elec\on b) rhe... ... .. parry, which is a registered unrecognised polr\cat parq rhat I am conresttng rhis election as an independent candidate. (Strike\ut which is nor applicable) and that the s).mbols I have chosen, in order ofpreferen\e. are: (i).................. .,.r ......(ii)................................. (iii)..... (d) my name and my farlier's/mothet's/husbandrs name have been corectly spelt out above in....hAff1.6.h.......... (name ol rhe Lnguage r: and (e) That to the besfofmy know ledge and beliei I am qualified and not also disqualified for being chosel to fill the seat in the Legislative Assembly ofthis State. * I further declare that I am a member ofthe...-....\...............I*Caste tribe which is a scheduled **caste/tribe ofthe State of.........................rn relati\ to............... ... ........(area) in that State. I also declare that I have not been, a.nd shall not be oominated as a candidat€ at the present the Legislative Assembly L) D 4 a: a / 7 ^t". /.-a: /.3 {* Scorc our rhe \ords nDi alplcablc iecosnned N.B A Politicdl pany Deans a pohical pany recosnisen by rhe El{tion CmGsion nnder rhe Eletion gmbols (R*eflario. lnd Alloxnmt) Order, I 968 in rhe Siaie concencd. PARTIIIA I (To be fiIedbythe caDdidale) (l) Whether the candjdate- (i) has been convicted- No (a) of any offence(s) under sub-section (l): or (b) for contravention ofany law specified in sub-section (2) people oIsecrion 8 trlrhe Repre(cnlalion o[lhe Acr. I a5l Yu.Nb"' (43 of 1951); or ii r has been convicred for an) olher offencer s r for which he has been senlenced lo impflsontnert lortuoyearsormore. No lfthe answer is "Yes". thc candidate shallI tumish the followirg infonnation , il01 ApPl,aalle (i) Case/First informarion No. \os. ............... !.' .. riirPoliceslalionts,.......\.....Oi"rricrts).....................Stalets)..................... (iii) Sectio(s) of rhe Act(s) and brief clescription of the offence(s) fo which I iv ) Dale(s ) of conviction( s 1....... 1............. (v) Cout(s) which cotrvicted the (vi) Punishmert(s) imposed [i period of imprisonment(s) and/or quartam of fine(s)l ............. (vii) Date(s) of release ftom prison.....,..... .i- (viii) Was/were any appeal(s)/revision(s) filed against above conviction(s).........yesAlo (ix) Date and particulars of the appeal(s)/application(s) for revision filed ................... (x) Name ofthe courr(s) before which the appeal(s)y'application(s) for revision filed. ... .. .. .. .. (xi) Whether the said appeal(s)/application(s) for revision has,&ave been disposed of or is/are pending.. ... .. (xii) If the said appea(syapplication(s) for revision has/have been disposed of_ (a) Darca5, oIdisposa1...... ........ (bt \arure olorderrstpa.<ed . (2) Whether the candidate is holding any office ol profit undcr the C,r ernme r ot lndia or State Government?.......... (Ycs/No) -IfYcs- dctails ofthc oflice held. (3) Whether the candidatc has been lared rnsohent by any Couil....-...... lYes/No) -IfYes, has he been discharged insolvency...............,...... (4) Whether the candidate is under al e or adhcrcncc 1() aDy forcign coLrniryl ... ....... (YcsAio) gr\e -ll Ye.. detarls \ . (i) Whcthcr rhe candidate has been ificd undcl scclion llA r)fthe said Act bv an ordcr of the President?. .. (Ycs./No) ll \ cs. th( periuJ,or trhrch dr.qualilrcd\................ (6) Whether the candidate was disilissed for on or tbr disloy.llty while holding oflice Lnrder thc (iovcnrmert oflndia or the ofany State'].. .. .. (YcsINo) lf \cs.rlreJrt<ot ruchdisrnissal..... .. (7) Whether thc candidde has any subsisting with ihe (;ovemnlent either in indi!idual capacity or by trust or parlrership iD which the candidale has x share fbr supp1,"- ofany goods to that GovemmeDt or for executlon ofworks undertaken bv that Govcmlllcnr' (Yes,Nol -If Yes, with which Govemment and details of subsisti4g contract(s)... (8) Wlether the candidate is a managing agent, or nanager or Secretary of any company or Corporation (other than a coopemtive society) in the capital of which the Ce]ltmy Govemment or State Govemment has not less than twenty-five percent share?.... -. .... -.. (Yes/no) -lfYes, with which Govemment and the details thereof. .. .. _ . (9) Whether the candidate has been disqualified by the Commission under section I 0A of rhe said Act...... (YesA{o) -llle.. rhc ddte oldisqualillcalioD................ ........ Phcc: thdttstqfdq 'Q-,.--^-l:i-.p..ti' Dar.: qj--fo3/QalJ Sisnalrrre of the candidate PART I\T seria r No. or nominat." o"o* . S.df4]:.htlix Thir nominatiol was delivered to me at mv rcanYdare th. nronoscr (Narnc,. Ra"-4 1- Rcturning 0fficei 'Score ou h. \rLd n.r )p|li.ahlc PART V rg Olficer Acceptirg orReject'ms lhe No-n1tr1*.1:"T" Decision of Retur with sectiou 36 oll the I have examined tlis nomination ffi y.,'**'a'de as follows: -- i n"p."ruotuiot oitl. feople Act, 195 t and decide Retuming Olficer (PerfoBtion)......... .... I or,r*p."xffi#{&J,r 09AA 410295 (See rule 4A) AiIdar it to be filed by the candidate along $,ith nominalion paper before the retuming officer tor.icclion ro . ( name of the House) from Brajrajnagar constituency (Name ofthe constitucncl) 06 Brairajnagar Asscmbly Conslituency. PART-A I . Ramesh Tdpathi. son of Anirudh Tripathi, Aged 52 years, resident of AT/Po'Bandhabahal, PS Banharplai, Distlharsuguda (Odisha), 768211, a candidate at the above election, do hereby solemnly affirm and state onoath as under: (1) I a[r a candidate set up bl Communist Party oflndia. (2) M) niune is enrolled in 06, Brajrajnagr, at Serial No 854 in Pan No 122 (i) \lt conlact telephone number is 94373:t6385 and my email id and ml social media account are :- (D rameshtripathr 2006ir!r!h!ele!1 (i0 Remeshtrapath) :- CPI (,1) Details ofPennanent Account Number (PAN) and status of liling ollncome Tax retum. Sl.No. Names PAN The financial year Total income shown for which the last in Income Tax return Income-tax return in Rs. has been filed l.' Self ACOPT2138E 20t8-19 6,50,875/- ?ABT OF AFF{DAVIT 2017 -18 5"54,363/- , w1/ HorAf,#JlftLuCIu *fu0).. 2016-17 6,4s,870/- 2015-16 5,56,370/- 2014-15 5,5s,070 2. Spouse AIBPP3388F 2018-19 7,80,156/- 2017 -r8 6,88,7 47 t- 2016-17 5,72,105/- 20ts-16 6,53,247 /- 2014-1s 5,23,485/- 3. Dependent N/A (Son) (5) I am/am not accused of any offence (s) punishable with imprisonment for two years or more in a pending case (s) in which a charge (s) has ,4rave been liamed by the court(s) of competent jurisdiction. If the deponent is accused of any such offence(s) he shall fumish the following information :- (i) The following case (s) is/are pending against me in which charges have been ftamed by for an offence punishable with imprisonment for two yeals or more :- irst Information Report NoA{os. together with Not applicable )te details of concemed Police t t41 ta Ls/Distri ctlState 'Inl B s) of the concemed Act(s) and short Not applicable \ re n ofthe offence(s) for which charged Y} -c*- Name of the Couft, Case No. and date of order Not applicable taking cognizance D Court(s) which framed the charge(s) Not applicable E Date(s) on which the charge(s) was/were ftamed Not applicable F Whether all or any of the proceedings(s) have been Not appticable stayed by aay Court(s) of competent judsdiction (ii) The following case(s) is/are pending against me in which cognizance has been taken by the court [other than the cases mentioned in item (i) above] : :;;W:: A:-^r-rr'".T'>;ff-AQ (a) FIR No.
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