og/or. t.2.+..< - X-)
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. (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 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. with Banharptai PS Case No. Closed Self name and address 22121-02-2011, cR Case acquittal of Police Station No.-265ll l, U/s-147, 341. (Ramesh Tripathi) concemed 283, 188, 294, 504, 506, 187, 149 IPC. Banharpali PS Case No. Closed and 23/21-02-20111 GR Case acquittal No. 267 l1l, U/s 332, 394, 307, 34lPC. Balharpali PS Case No. Pending at 59/15-06-16, Uls 143, S.D.J.M, 144, 341, 323, 294, 506, Court, I49 IPC. Jharsuguda Banharpati PS Case No. Pending at 151/28-12-17, S 406, S.D.J.M, 420,294,506,34. Court, /r a> Jharsuguda GR 706/20r r Pending at 7ro, U/s 341, 294, 506, 34 S.DJ.M. Court, :,?J, IPC. Jharsuguda o \c i{bq Burla PS Case No. Pending at \ 133/22-07 -2010, Uls 143, S.D.J.M. f9D 148,427, 149 tPC Court, Sambalpur CMC Case No.10/19 Sub Divisional U/s I I Cr.P.C Magistrate, Jharsuguda (b) FIR No. with Baaharpali PS Case No. Pending at Spousc name and address 151/28-12-17, u/S 406, S.D.J.M, (Sunita Panda) of Police Station 420,294,506,34. Court, concemed Jharsuguda CMC Case No. 15 of Pending at 2014, GR Case No.o8/14 S.D.J.M Court Uls379/34,457 Cr.P.C. Jharsuguda ct 10422/2010 Pending at U/s 177 /192 , S.D.J.M. Court MV Act 18-03-12 Bhubarteswar PABT O j &1/ P. N TIWARI NOTARY, JHARSUGUDA P--,,"OUt-o )V)q (6) I have not been convicted of an offence (s) [other than any offence(s) referred to in sub- section (I) or sub-section(2) or covered in sub-section (3), of section 8 of the Representation ofthe People Act, 1951 (43 of 1951)l and sentenced to imprisonment for one year or more. Ifthe deponent is convicted and punished as aforesaid, he shall fumish the following information; In the following cases, I have been convicted aad sentenced to imprisonment by a court of law: The details ofcases, Section(s) ofthe Not applicable concemed Act(s) ard description ofthe offence(s) for which convicted B Name ofthe Courl(s), Case No. and Not applicable date(s) of order(s c Punishment imposed Not applicable D Whether any appeal was/has been filed Not applicable against the conviction order. If so, details present {;'S and the status ofthe appeal I {**o o, ".\} .,{Q,r{agpirg lt rein below the details of the assets (movable aad immovable etc.) ofmyse1l 6:r.,. mJ e?'ousf a d all dependents: .,,1 o;% '.'4 , 9*\*dl--r," L"-. able assets : Note : 1. Assets in Joint name indicating the extent of ioint omership 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 the BanMnstitution and Branch are to be given. Note : 3. Value ofBonds/Share Debentures as per curent market value in stock exchange in respect oflisted companies and as per books in case ofnonlisted companies should be given. Note : 4. Dependent here the same meaning as assigned in Explanation (V) under section 75A ofthe Representation ofthe People Act, 1951. Note : 5. Details including amount is to be given separately in respect ofeach investment ,A8r oF ffiloavn Horaiv)rr,.L[*[tuoo A=*^--*\ tlzrf^)i Description Self Spouse Dependent No.l Ramesh Tripathi Sunita Panda Abhilekh Tripathi (Son) Cash in hand 4,50,000/- '7,50,000/- No Details of SBI Nc, Rs. SBI Nc, Rs. SBI Rs. deposit in Bandhabahal 1,25,000/- Bandhabaha 71 ,662/- Bandhabaha 1874/- Bank Branch 1 Branch 1 Brarch accounts Nc No. Nc No. Nc No. (FDRs, Term 10746856107 t07468459s 3218926125 Deposits and 7 5 all other types of deposits SBI Nc, Doment SBI A./c, IB including Bardhabahal Thermal Rs. saving Branch Branch 18352/- accounts), Nc No. A/c No. Deposits with 200974691'7 4 10'76s79845 Finaacial 8 Institutions, Non- Banting PNB, Rs.25,137l- Bolangir Closed Finarcial Bandhabahal Anchalika Companies Branch Gramin A/C ard No. Bartk 044200010006 A/c No. Cooperative s248 4331 societies ard t}Ie amount in Bank of India, Rs. Bank of Rs. each such Jharsuguda 16.700/- India, 1156/- Branch Jharsuguda A/c No. Branch t-\ 557010110009 A-lc No. 9,o^ 412 5570101100 ts' 09453 6-7;1^ t< '{tu, iir.+1" '.\'--1 ,b, ?, Central Bank Rs. PNB, _\9N of Indi4 1,1.848/- Bandhabaha Kumarbandh I Branch Bmcnch A,/c No. A,/c No. 2227723473 OF AFFIOA IT I " o t,/'' "._r,', o r.r i'i r Aiil i I NoTAhV, Jr'Ai6uGuDA A-"""D1^T,;{'"^uZ Union Bank of Doment i tnaiu. I Bandhabahal Inraoct I A./c No. 36520201000i lst: I I I mel uunk. DoIment I Jharsuguda Bmnch ] A/" Nn lz+oro+oooooe I egs I ICICI Bank Doment Bhubaneshwar Branch A-lc No. 006101507693 Bank of Rs.1,024l- Baroda, Domrent Bhubaneswar Baraach A-lc No. 325401000016 42 Donnent HDFC Bar* , Jharuuguda -glx""+\ Branch, .r, /.a \- No. totb 1A,/c i\Yr:'ii,iii-1 \ ,p763 r0000r 27 7[o" rIl ,c\ i ',t '.:,,').tz II -*c*n"e % n-/ Axix Ballk , RS. s * Belpahar 2,10,000/- Bamch A/c No. 9180r0113878 t33 Total 8,42,709t- 8,41,1701- 1874t- l- ' P. N TIWARI BOTARY, JHAR5I,JGUDA Q,-^-"',""1,t **'9 Detaits of PNR 90,000/- PNB 21 ,7 5|- SBI 6,000/- Fixed Deposit Date of 3t t03/202t Date of 19t01/2021 Date of 26t10t2019 Maturity Matullty Maturit], PNB s0,000/- SBI l'7,'718/- SRI 913',11- Date of 29t03t2022 Date of 03108/2028 Date of 29101/2023 Maturity Matudty Maturity PNB 55,000/- PNB 25,000/- Date of 31/03/2023 Date of 3t/0312022 Maturity Matudty SBI 55.141/- PNB 20.0001- Date of 19/04/2022 Date of 31/03t2021 matu ty Maturity 0 Bank oflndia 90,000/- SBI 1,1,838/- 314 Date of 27104t)0)0 Date of 20/05/2018 ffi Maturity Maturity P\ \. Banl< oflndia 60.000/- Bank of ,10.000/- India w Date of 31/03/2023 Maturity Date of 31t03/2023 Matu ty Total ,1,00.1 4,1/- 1,39,361t- 15,137/- Details of investmelt in NO NO NO Bonds, debertures/sh ares ard units in compa.nies^4 utual funds and others and the amount P'8T OF AFFIDAVIT f' 4ir P. N TIWARI e*-rlY;T"t+$ NOTARY, ]}TARSUGUDA Details of Bharati AXA 2,50,000/- LIC inYestment in Nit NSS, Postal Date of Policy No. Amoutrt Matuity 28/031)020 Saving , Insurance s94602492 50,000/- LIC policies and No. investment in ts!!q 595003901 1,50,000/- any Financial 594602487 6,40,000/- 594602494 50,000/- instruments in Post office or s94602493 50,000/- Insurance 594309697 3,00,000/- Company ard 591335995 1,00,000/- the amount 59s003299 1,00,000/- 59t690824 50,000i- 593282096 50,000/- 592131216 1,00,000/- ( 59430969',7 1,00,000/- ol, s9460248',7 1,00,000/- s Total 12,90,000/- 8,00,000/- Nir Plis*&<- loans/ advaace Nil Nit Ni1 given to any person or entity including firm, company! Trust etc., and other receivables from debtors ard the amount Motor oR-23 9225 Tata 2515 oR-23D Bolero Nil Vehicles/ TrucK 2005 7625 SLE AircraAs/ Yachts/Ships (Details of Rs. Rs. Make, 5,00,000/- 2,00,000/- PAET OF AFFIDAVIT t 'n't- To;v^$ P. N TIWARI A---*rrl" NOTARY, JHARSUGUDA regisftation oR-23 9083 Tata25l5 oD-23D Bolero number Truck 2005 0868 Pickup etc. year of Van puchase and Rs. Rs. amount) 5,00,000/- 3,00,000/- oR-23F Tata25l5 oD-23D Bolero 0774 TrucK 2012 3912 Pickup (Loan Van Rs. Amount- Rs. 8,00,000/- 7211/-) 3,00,000/- oR-15K Lelald oD-23E Bolero 47 69 Tarus 2006 1004 Pickup (Loan Van Rs. Amount- Rs. 6,00,000/- 98732/-) 3,50,000/- oD-23H Letand oD-238 Bolero 1849 (Loan Captair 964 Pickup Amount- 2018 (Loan Van 3 5 ,54,650/-) Amount- Rs. 3,15,300/-) 3,50,000/- Rs. ':ft^, 40,00,000/- -?r.3w" oD-23H Leland oD-238 Bolero 1850 (Loaa Captain 9165 Pickup Amount- 2018 (Loan Van 35 ,54,650/-) Amount- Rs. Rs. 3,15,300/-) 3,50,000/- 40,00,000/- oD-23H Letand oD-23 Maruti 1852 (Loan Captain 5084 WagonR Amount- 2018 (Loan 3s ,s4,6s0/-) Amol.mt- Rs. 66604/-) Rs. 40,00,000/- 4,00,000/- P.N TIWARI TIOTARY, {iLtB JHARSUCuOA e---,./Yh ^a oD-23H Leland oD-23c Hero 2049 Captain 4467 Activa (Loan 2018 (Loan Scooty Amount- Amount- 3s,s4,6s0/-) Rs. 2t,877 /-) Rs. 40,00,000/- s0,000/- oD-23H Captain 2050 (Loan 2018 Amount- 35 ,54,650 /-) Rs. 40,00.000/- oD-23 9287 Bolero (sale (Loan to D. Amount- Gouda) t32s/-) oD-238 407 Pick:up 5',701 (Sale to B. - (\ Naik) 2'.. F ?A' ,?ruzo^ oD-23G Bolero SLE bt \E cl ii nz' /< 6218 (Loan Amount- Rs. "a ", 5,48,000/-) 5,00,000/- oD-02H Mestro 4026 Scooty (Sale to Suresh Tripathi) Rs. Rs. 2,29,00.,000 23,00,000/ PABT OF AFFTDAVIT I bu. P.N TIWARI NOTARY, JHARSUGUOA Q-,t-",r4.I>raP^&: Jewellery, Rs.1,00,0001 Rs.7,00,000/- bullion and Valuable thing (s) (give details of weight and value) Any other assets such as value of claims/interes t Gross Total Rs.2,55,32,853/- Rs.47,80,537/- Nil Value "11- B. Dt ails of Immovahle Assefs : Note 1. Propefiies in joint o*nership indicating the extent ofioint orvnership will also have to be indicated 2. Each land or buildinsding or apartmentaDartment should he mentioned seoaxatelvsepaxately in this format Descdption Self Spouse Dcpendent-1 (Ramesh Tripathi) (Sunita Panda) Abhilekh Tripathi (Son) (i) Agricultural Land Khata No.2451275, Nit Nil Location(s) Survey Sarla Mouza, numbe{s) Bargarh District Area (total Ac.0.50 decs. Nit Nil measurement in affes) Whether inherited Yes Nil Nil property (Yes or No) Dale of puchase in Nir Nil Nil case of self-acquired ploperty AFF IDAVIT iPABT OF 4,,' O*--,--t" T,-nP"4: o hl TlwARl HorrkV, :ileRsuGut'A Cost of Lard (in case of purchase) at the time of Any investment on the land by way of development, construction etc Approximate curent 1,00,000/- market value ii) Non-Agricultural Khata No.245l53 Khata No.631 Land : Sarla Mouza Fatak Sakhi Location(s) Bargarh District Gopinath Survey number(s) Mouza, Khata No.437l408 Sambalpur Burla Mouza District Sambalpur DistricX Khata No.108/257 Zs*F-fl Kirarama d, s".T -'-' u Mouza, Jharsuguda r:1t$$ District '\ 4 _., Khata No.741137 Chingriguda Mouza Jharsuguda District Area (total 1. Ac.0.060 decs. l. Ac.0,015 measurement in sq. ft.) 2. Ac.0.070 decs. Ac.0.420 decs. 4. Ac.0.80 decs Whether inhe ted 1. Yes property 2. No (Yes or No 3. No 4. No Date of purchase in 1. N/A t. 19/05t92 case of 2. tUt2t95 self-acquired property 3. 06t06fi8 4. 17 t02197 F /\ (.r-_ O N TIWARI b ) r '^ ,l_L- touhV' .r'ilansuouor lZa''- */L^ \ Qt Pc _ Cost of Land (in case 1. N/A 1. 10,000/- of purchase) at the 7 28,000/- time ofpurchase 3,36,000/- 4. 16,s00/- Any investmenl on the 1. Nil 1.5,00,000/- laad by way of 2. Nil development, 3. Rs.10,00,000/- conshrlction etc. 4. Nil Apprcximate culrent 1. 1,00,000/- 1. 10,00,000/- market value 7 7,00,000/- 3. 50,00,000/- 4. 50,00,000/- (iii) Commercial Nil Nil Nit Buildings (including apartments) Location(s) Survey number(s) Area (total Nil Nil NiI measurcmcnt iD sq. ft.) Built up area (total Nil Nil Nil measurement in sq. ft.) Whether inhedted Nil Nil Nit property (Yes or No) Date of puchase in Nil Nil Nil case of self-aaquircd property Cost of propedy (in Nil Nil Nil case of purchase) at the time ofpurchase Any i[vestment on the property by way of (t/ [ 1A T i]t: AFTIDAV IT .{l t:I .t o' .r Irri I :<: u Lbl -rd- \s\BFi D N i$lb Rl \{r\) z .I Q--^^ $,+\ E./)i(orliri ri'."aSUCUOa ^+ T>;Pil< ApEoximate curent Nit Nit Nil market value iv)Residential Nil Khata No. 673 Nil Buitdings (including Flat- 506, 5e Floor apartments) Badrigarden Appt. Location(s) -Survey ru/5 5-s, number(s) Area (total Chnadrasekharpur, measurement in sq. ft.) Bhubaneswar Whether inherited Nir Nil Nil property (Yes or No) Date of pwchase in Nil 21t1U20t4 Nit case of self-acquired property Cost of properry (in Nil Rs.35,00,000/- NiI case of purchase) at the time ofpurchase Any investment on the Nil s,00,000/- Nil land by way of development, construction etc. Approximate cuaent Nit s0,00,000/- Nir market value (v) Others (such as Nil Nit Nit intercst in property) (vi) Total of crment 1,09,00,000/- 60,00,000/- NiI market value of (i) to (v) above ,/'- t efiEet o(1] :- . "{ t -i ',: 1 $69* * oF {Ff,,DAv,r rornni'rilfttLuo,rFlrtwan, -I>2:l^^14--- O^\(_-Q><,zt--^/v/W., ^t J (8) I give herein below the details ofliabilities/dues to public financial institutions and government i (Note : please give separate details ofname ofbank, institulion, entity or individual and amount before each item) Description Self Spouse Dependent- l @amesh Tripathi) (Sunita Panda) Abhilekl Tripathi (Son) i) Loan or dues to (t)t,87 ,73,250t- t) 7,211/- Bank/finarciat Kotak Bank P\t, (Mahendra & institution(s) Ltd) Mahendra Finaace Name of the Bank or (2)7,00,000/- Ltd) fiaarcial institution, (Mahendra & ) 98,732t- Amount outstanding, Mahendra Finance (HDB Financial Ltd.) Service) ) 5,50.000/- (Kotak Bar]k P.Lrd) 4) 66,604/- 7;t*) SBI, IB Thermal) s) 21,877 t- t';,,;_\ SBI. IB Thermal (1) 3,00,000/- (Sanjib Tripathi) individuals/entity (2) s,00,000/- other (Petrol Pump, than mentioned Anshita Fuel ard above Baladebji Fuels) Name(s), Amount outstanding, natue of loan Any other liability Graad total of 2,02,73250/- liabilities !nr'_o'6rr*,, A------(^'{I.-lrya NorA{r:;reflLuDa (ii) Govemment Nil Ni1 Nil dues : Dues to departments dealing with govemment accommodation Dues to department Nit NiI Nil dealing with supply ofwater Dues to department Nil Ni1 Nil dealing with supply of electricity Dues to depafiment Nil Nil Ni1 dealing with supply of telephones/mobiles Dues to department Ni1 Nil Nil dealing witlt govemment farsport (including aircrafts and helicopters Income tax dues Nil Nil Nil Wealth tax dues Nil Ni1 Nil Seruice tax dues Nit Nil Nil Municipal/Property Ni1 Ni1 Ni1 Tax dues -* eo /c?/'* - T OF AFFIDAVIT l3*"'*'.'.'i tut. c-t-u o ; | t+' P N 1'IWARI /,:--*-LJTa-^v \C .bH';'.t.h-:i 'E ARY, JHARSUGUDA Nil Nil Tax dues Nil -sales Nil Nil other dues Nil -Any Nil 6-ii;crand total of Nil Nit all Govemment dues Nil Nil iv) Whether anY Ni1 other tiabilities aIe in dispute, if so, mention the amount involved and the authority G'hr.e which it is :.r,ie} f profession or occuPation : :-Business .. . (a{ resh TriPathi) BuSlnCSS . rb1 sunita Panda)i Service and is as under ''zr"lh r e ationalqualification (.mhalnt ffi\qeIS4 .^ll^-^ rr G.M.UOllege, )anrDdrlrur LLB, L.R.Law college, SambalPur PART-B GiVEN IN (1) TO (10) OF PART'A : ( 11) ABSTRACT OF THE DETAILS Ramesh TriPathi I Nam-f thecandidate Sh /Smt '{(um a-r,ryo-gandhubahal,ps-Banharpli,Dist- 2. Full postal address Jharsugurla (Odisha)' P\tI 6821 l' and G,nruiruSnfi ast"mutYconrtitu"n"Y' 3-.Nu*b", *d,rr-" of tt'" constituency Purty of Ldiu +.-N iolfi" poti,l.al pafly which set up e--onlrrr*itt the cardidate lotherwise write Independenl iPAET OFtil- AFFIDAVIT ?rfqi P. T|WARI NOTARY, JHARSUSUDA . (i) Totat number ofpending cases where Ni1 charges have been framed b) the Court for offences puoishable with imprisonment for two yeaxs or more ii)Total rumber ofpending cases where Nil the coufl(s) have taken cognizance [other than the cases mentioned in item (i)above 6. Total Number ofcases in which convicted Ni1 and sentenced to imprisonme[t for one year or more [except for offences refered to in sub-sections(1), (2) or (3) ofsection 8 ofRepresentation ofthe People Act, 19511. PANNO. Year for which last Total income shown Income Tax Retumed File (a)Candidate ACOPT213 8E 2018- l9 6,s0,87 5/- #E\(b)Spouse AIBPP3388F 2018-19 7,80,15 6/- f n;ioil and Liabilities in Rupees # {ARI I Description Self Spouse Dependent-I (Ramesh Tripathi) (Sunita Panda) (Abhilekh Tripathi) s );MovdibleT' essets 2,39,00,000/- 28,00,000/- Nil !'i}.Hd"rulo..1 B. Immovable Asset 1,50,00,000/- 60,00,000/- Ni1 I. Purchase Price of 1,50,00,000/- 60,00,000/- Nil self acquired immovable DroDefv II. Developmen 50,00,000/- 50.00,000/- NiI construction cost of immovable property after purchase (if applicable . ApFoximate Culrent market price of oFdittD^vfi l^8r , xoraf;il.IlI$t[uo* a) self-acquircd assets 3,89,00,000/- 88,00,000/- Nil (Total Value) (b) inherited assets 2,00,0001- Nil Nil (Total Value) 9. Liabilities i) Govemment dues Nil Nil Nit (Total) ii) Loans ftom Bant, 2,02,73,250/- '7,41.121/- Ni1 Financial INtitutions and other (Total) 10. Liabilities that are Nil Nil Nil under dispute (i) Govemment dues Nil Nil Ni1 (Total) 11. Highest BA-G.M..College, BA- c.M..College, +2 Science- educational Sambalpur, Sambalpur Sambalpur, Sambalpw Chandrasekharpur qualification : University Univemity DAV. Bhubaneswar. MA- G.M..Co11ege, MA- G.M..Co11ege, B.Tech-Vcllor Sambalpur, Sambalpur Sambalpur, Sambalpur Institute of University University Technology. Tamilnadu(Continue) LLB-LR Law College, LLB-LR Law College, Sambalpw, Sambalpur Sambalpur, Sambalpur Universitu University B.ed- Rabishankar U versity, Chattisgarh lfo re h ,-\\ / PEAi/rD \ \ .,. /ilAR ' ',,yaR'\ ' *l Nfil'r €l Y l* I Jlunsr"..:.rla / , \ REGU. Na_ / / N-01/9j-4l .--\,4 Vo-roQ.)r A-r----^)^(l>-^P iPART OFTi/ AEiIDAVIT p.N Trtsr4 Rl NOTAnY, it+aitSLitutlnA },ERIFICATION I, the deponent above named do herby verifu and declare that the contents of this affidavit are true and conect to the best ofmy knowledge and belief and no parl of it is false and nothing material has been concealed there from. I ftrther declare that:- (a) there to no case of conviction or pending case against me other than those mentioned in items 5 and 6 ofParl A and B above; (b) I, my spouse, or my dependents do not have any asset or liability, other than those mentioned in items 7 and 8 ofpart A and items 8, 9 ard 10 ofpart B above. G- 6,"]'ry' Verified this tty'e 25 dal ol March 2019 Q*^--^'T=ie4a DEPONENT r-1:(, 4u)'r ,"r^ir::ffiliif:yfX[ffi],^i*,E*^^, il,-:dfiYi,rJ rhe depohent'soterlttv f/lTlil ^.", '"i13'r""i'5=-f ,;mm' -?Ri;", xomri"FransucuPr T ) ) 0Drs i A' "R;; - o t D No. o N !bl.\rl 09pA 410291 \!*.*t ilo. Sl. -'z'=- BEFORE THE NOTARY PUBLIC, JIIARSUGUDA tl AT IDA\'IT I, S . Ramesh Tripathi. aged about 52 years, S/o-Anirudh Tripathi. resident ol AT/PO- Bandhabahal, PS-Banharpali. Dist-Jharsuguda (Odisha) do hereby solennl! allirm and state as lollou s:- 1. Thar. in m,v Voter ldentity Card, l11) rame has been lecorded as Ramesh Tripathi. 2. That, in my educational ceftificate, Aadhar Card, PAN Card and other docunents nly name has been rvritten as Rmcsh Kumar lripathi. 3. That, Ramesh Kumar Tripalhi and Ramesh Tripalhi are the names ol samc and one i.e. mine none e1se. 4. That, i am s\\'ea ng this affidavit in order to produce it belbre the concemcd authorit,v whenever required. t he lacts statcd above are a1i tnre and corect to the best ofmy knowledge and bcliel ldentified h14re {fr- -- |tfr-,*"/t/ Ear-".sh \aatrar'1 .\dioc/te. JharsrLguda"- Deponent Tha do{ra6ent solemnlv affi..ns before adv- a' ,lU r.-/ roday at ---!-ffif,niFF-t ,,hcdi ft-.,-3b*-ffi IIOTASY, JH.ARSUGUDA t fo-.. €L*.64"f'-r.At . . STArllP VEIY.DOR IIlARSJAI IDA I I FORM OF OATH ORAFFIRMATION oF lNgAl 173 (A) oF THE CoNsrrrurloN I ARncLE 9;ate) or aectan to the Legistature of a fo o" ,ua, ii , *nia)te' having been nominated slativ€ ?le{--a-. r- - #'derlLegi t,,l a seat in the sfar"B' "" " ""ni'iJ. f"il:*::*",:'f n:"ffi #8',:.:;"1:::tJffi II"*n** o'''*,1ff::tTly,.:l'JiT:l fff l?11"1'-"r':::ffi ;::llffi "'''on "" ""t"urb$|di) lndia' sovereignrv* and integrity of lo;r,4 I will uphold the tani{ffifi1,sru4t; in block letters of the candidate in the sW'd' ... (Place) at me oi.....Llx. *...-.zo 'JP- "" before a?q16,1 xtv'- q6)0 q.. 511 aqa qsc RECEIPTBOOK 0018 58 4 a', 066t 66,|06,qoa$ qse, [ 1963 6qfl 31(D gqoq ] qs6,a.. /6 ?Aet 2O/g araroQ gtg 6onl /ar"tn/- 6fl161 A 1, qg6)laq 0. s. (otaa)oTp"-21 7--2o,ooo Bks.06-06-201 4 si,+. l FORM A Communication with regard to Authorised Percons to intlmate names of Candidates set up t y recoqnised NATIONAL OR STATE Political party oTREGISTERED UN-RECOGNISED political party. (See paragraph 1il(c), (1)and (e)ofthe Electicn Symbols (Reservation and Aliotnrenl) Ord,:i. 1968.) 1. The Chief Elecloral Oflicer; ...... -.(Stale/Union lefiilory) 2. The Retuflriig Olficer for the 6 - BBntn BA.f NA6,4,&cctnsrttuencv. LE6TS L+ )VE ASSEMBLY Slbject:- ceneral Electionsto...-..a...... fronAAl.J.HA.(State/Ur1ien-l@t+i{ery)'-Allotmentof Syribols -Authorisalion of persons lo intimale namos of carldidates. Sr, ln pursuirnce of paragraph 13(c),(d)and(e)oiiheEecllorSynbols(ReselVationandAlioknent)Order, 1968, hereby communicate that ihe fo loriing person {slhas/heve been aLlthorised by the party which ls National Pariy/ktePart in the Stale of /Raagl€I€+e#htrecognised Party to intlmale tle names ol the candidates proposed 1{) be set up by the party at the electiof cited above. Name of person authorised Name o{ olfice held in the Districi(s)/area (s) consiituency/ to send notice party constiiuencies ir respect of whlch he has been authorised. 1 2 3 1 Agt'tts KANuNqo c,Tu-rc lprpcrtpv QhB at I THF 2.+ /ahtllJA anNlrtfuFAI ( tF1 3=-- /nutttt ttrtr 1 lnseded by Notificalian llo. 56/97/ludl'tll, datscl 1 5 1 2.1997 16 The speclmen signatures of the above mentioned person (s)so authorised are given below:_ 1. Specimen srsnarures of shi ..As.H.r5...KANU.N.60...... t! fl A A <:^.q 1 1 .fi2.L,3. .u.a-. rl kmt t 2. Specirnen signal (!) ...... ) {iri) ...... } (i) ...... (ii) (iii) ...... Yourc faithfully, ,tb$r1fuW Pres denUSecretary Presidenl/Secretary Phc. .N.EW..D.ELHl Name of the Paity oate ..2A.:.03.:.2aJQ OMMUNIST PARTY OF INDIA (Seal oi the Fa(y) NB, 1. This musi be delivcred to the Returning Olficer and the Chief Electoral Officer not iater ih.n 3 p,nr, on the lasldaie for maktng nominalions. 2. Fornr must be signed ir] lnk by the office bearer (s) nlenlioned above. No facsimile signature or signature by means of rubber stamp, etc., of any office bearer shall be accepted. 3. No form transmitted by fax shall b-. acc.-'pted. a7 }.ORM B NOTICE A,S TO NI.ME OII C.ANDIDATI, SET UP BY TIItr POLITICA]- I'AT{ T Y ISEE 't PALAGRAPIIS t3(B), (C) ,{ND (E) AND l3A OF Tm ELECTTON SYMBOLS (RXSERVATION .A.ND TILLOTMENT) ORDER 196BI 'I'o The keruminsOfficer for rhe HR Al A N AuARi....consr;n,.n.1 o RAJ . LL6rSLArrr t A9st MBLy \Ao AB Subjecr'ceneral,lbreEleciolto...... f..,Q...l1l(^llll.ln,..ofthcConstirucncy)- " " ^aAJ in. O D lS H A. ...{StareAlsio!_Ie+irery) - scilins up ;icandidare. Sir, Ii.pumuan.e pam-qraphs of 13 (b), (c) and (e.) and tjA_uf rtrc Etedio4 S_vmbots {Reservarior and Allormenll order. too8 Iherebygiven,,riceoflL.hatror.of.Md{rsi PtBryJ ot LNDTA rhs {r} that fer:on whosc pr(iculars are turnishc.d in columns {2) to (4) betow is thc approvcd candidale of the part), abovc named , and (ii) the person whose particulars are menrioned in colunrrs (5) td7) belo*, is rhe subsrirrte candidate of tle parry, rvho \!ill st.p in on rhc approved ca didale.s lominarion bcinq reje.tcd ofl scrutiny or on his u,ithdrarvins irom tl;contcst, if the substitute cardidate ii still ll contestingcandidat€, at th.ttl. erluing genemLlbye election from this Namc ofthe Substitute .a diJai. whc willsle? in Mothe.sl H!ib&.ld s {i) on ile app.ovod caMidate\ nomination being rcjected cn s.rutiflt,, iii) on his (approv.J .andidatc) nirhdrawing iiom {l). ccntesl it howevcr, ths nominarion pap.. of subslituie .anCidaie rs accepted oo rcruliny an ird?end.nt candidxte'l and is :dll a cont.sting candidate T,. 2 1 5 5 7 &cz s< :ft =*4 af- C\T 3+g-x i 3v --\ l__ + 3._It is ce(ified (har each ofthe can.jidales *j(rse flame is ncntioned above is a memlnr. political parry and "'""',', oj it rl his name is duly borne oo th. pr"y.' -ff, "fr,"",t "." "i,fr" Yours faithfllly. AaA iz Koatn qE (ASH ts KANUN 6o )a (Name and Sigraiuro oi ii.i. Autho.ised person of the prrty) (Sealofthe Party) p (Seal ofrhe pany) b,. . B. h.tt b. e n e.s a a r Dat" .2.0.- a3 -.2 0t 9 * Score of, if not applicabte. N.B- l. Ihis must hedeiivercd to the Rerumirg Oflicer not later than 3 p.m_ on the last date for irrkirg nominations. 2. Form must be signcd in bl rhe ir* oflice bearer(s) mentioned above. No facsimile s,gn:r!,, ,, signature by means ofrubber slarnp, etc_, ofany officc be €r shall be ac.epted. 3. No form tmnsmitted by far shallbe acccpied. 4. I'ara 2 of dre Forn must be score.l of| if not applicable, or must be properl, ii)j.,(i i: applicablo.