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FORM 2A (^See mle 4) NOMINATION PAPER . Election to the House of the people z44rt e/- r: lsl-) I oslHpl^m\e" : STRIKE OFF PART I OR PART II BELOW WHICHEVER IS NOTAPPLICABLE (To be used by candidate set up by recognised political party) Constituency. ".g";^;- a v T1,., I &l. ,3'u t1 Date Signature of Proposer PART II (To be used bY cafldidate NOT set uP b ised political partY) of the People from the.... We hereby nominate as candidate for eiection to the Parliamentary C onstituencY Candidate's name. Father's/mother's/husband's name........ """"His postal address 'l of the electoral His name is entered at S.No....""""""""in Part No' y constituency compris.ed within) y and our riames are W.e deolare that we are electors of the above Parliamentary as indicated below and we entered in the electoral roll for that Parliamentary Consti append our signatures below in token of subscribing to this Particulars of the proposers and their s Sl.no: 1 1' 7 J 4. 5 6 7 .8 9' 10 N.B.- There should be ten electors of the constituency as proposers. 2 N/P- PART III I' the candidate mentioned in Part ,y*((Strike out which is not applicable) assent to this nomination and hereby declare-- (a) that I am a citizenof India and have not acquired the citizenship of any foreign State/country. that I have (b) complered..... .6.0.. .............years of age; ISTRIKE OUT c(i) or c(ii) BELOW WHICHEVER rs Nor APPLTCABLE] (c) (r) that r am set up at this election by the.... ItJ,rn* cauma- parry, which is a recognised National Parfy/State Party in ^lC?.'M.this State and tt ut [" symbol reserved for the above.party be allotted to me. o (c) (ii) that I am set up ?t this elefon by the parfy, which is a regiStered- ised politic al pafi/that I am contesting this election as an independent /ndidate.'(Strike out which is not applicable) and that the symbols I have in order of preference, are:- (d) that my name and my father's/mother'slhusband's name have been correctly spelt out above i"..WeI*-..... (name of the language); (e) that to the best of my knowledge and belief I am qualified and not also disqualifled for being chosen to fill the seat in the House of the people. relation to... ...Mntt.,.f*"uj in thar State. ! I also declare that I have not been, and shall not be nominated as a candid ate atthe present general election/the bye-elections being held simultaneously, to the House of the People from ! more than two Parliamentary Constifuencies. 3 .&o Ig nut.....8.{. Sigffiture of Candidate TScore out thewords "assembly constituency comprisedwithin" in the case of Jammu and Kashmir, Andaman and Nicobar Islands , Chandigarh, Dadra and Nagar Haveli, Daman and Diu and Lal<shadweep. 3 *Score out this paragraph, if not applicable' **Score out thewords not applicable' N.B.-A,,recognisedpoliticalparty|,mennsapoliticclpartyrecognisedbytheElectionCommission Allotment) Orderi 1968 in the State concerned' under the Election Symbols (Reservation and PART IIIA (To be fitled bY the candidate) (1) Whether the candidate- (D has been convicted- (a) ofany offence(s) under sub-section (1); or (2), of section (b) for contravention of any law specified in sub-section (43 1951); or YesA'{c 8 of the Representation of the Pebpl'e Act, 1951 of which he has been (ii) has been convicted for any other offence(s). for sentenced to imprisonment for two yearS or more' "Yes", the candidate shall furnish the following informatiort: If the answer is : (i) Case/first information report No'A{os" " for u'hich (iii) Section(s) of the concerned Act(s) and brief description of t e offence(s) he has been convicted ......... l\/..A (,v) Date(s) of conviction(s) ........[l.A (v) Court(s)whichconvictedthecandidat6..... M &......' x (vr) Punishment(s) imposed findicate period of i t(s) aird/or quantum o{' fine(s)1. Nl.* NI (vii) Date(s) of release from prison............'.Y. ,\l. (viii) Waslw eryany appeal(s)/revision(s) fi led against above viction(s)...Nf .... /\ YesAio M-4g- (ix) Date and parricurars of appeat(s)/application(s) for revision fired. ....M.|t (x) Name of the court(s) before which the appeal(s/application(s) --:"urvs for revision fiied. ..M.fi- . -. .:...::....................-..........:.:l.......... (xi) whether the said appeal(s/application(s) for revision has/have been dispo."o is/are pending....... oro, : A/ ft lltav ebeen disposed of- (a) Date(s) of disposat l\l.fr.. (b) Nature of order(s) passed. .M.fl: whether @ the candidate is holding.any office of profit under the Govemment of India or State Government?......... lVegnf6; ,r/ (3''i whether the canditlate has been declared insolvent by any court?.......:.. (yes/Irlo) -If Yes,,has he been discharged from insolvency........0!m (4) wnetnyz$e candidate is under allegiance or adherence to any foreign country?......... (YesAI.o) -If Yes, give details . NIt.k (5) Whether the candidate has been disqyntffied under section 8A of the said Act by an order of the Presidenti. 1verffi -' -If Yes,.the perio.d fo.r rvhich disqualified.... nf ' .4. (6) Whether the candidate was dismissed for comrption or for disloyairydisloyaity *'hilewhile holdjnotg*goffice under the Government of India or the Government of any State? .........(yesAfo) -iri.r, irrc date of such dismissar......M:. t..... (7) Whether the candidate has any subsisting contract(s) fyith the Government either in individual capacity or by trust or partnership in which the candidate has a share for supply of any goods to that gr6*^"nt or for execution of works undertaken by that Government?.............. (YesA[o; -IfYes, with which Government and details of subsisting contract(s). .. ft 'f (8)Whetherthecandidateisamanagingagent,orrlanagerorSecretaryofanycompany orCorporation(otherthana,oo,**elcieu]inthecapitalofwhichtheCentral than twenty-five percent share?"""""' state Government has not less Governrp6t--/ or (Yes/no) INAY: ::"::::::*:::"1:T:"-'.:::::.'re" 10A of the by the commission under section whether.the candidat ehasbez,Kwalifietl (g) i (YesNo) said Actt:. ... ] -If yes, the date of disqualification' ''{'f- t W . a t. Signature of candidate 1 Place: .P\fi?:k \J I ! t Date: . r)" t1 , '..s.,10 i PART IV (To be filled by the Retuming Officer) seriat No. of nomination paper ..0{..tf/X.f.f f 1.9 This nomination was delivered to me at my office u*.....t,.1-g.t(hour) *..*.t{.attf...., (date)bytheltg4ndid41olhr€po€€r.(nameofproposer............. ......................) ! @/.-- Retuming Officer . PART V Decision of Returning OfficerAccepting or Rejecting the Nomination Paper I have examined this nomination paper in accordance with section 36 ofthe Representation of the People Act, 1951(43 of 1951) and decide as follows:- Returning Officer (Perforation) ............. crorool o<rro(} aoolooTbotJ:!, o(i- eeodbd,E'err*r stvr ANDHRA rRADEsH G' :i- ..t. cH.sfihiqTfrm,on {94o.i:"e- &l:oB-Boq, . ,*. frlo. o8-.81s-ClOl.i 2013 \,,,,, ]. 1 9'20?1 IS-*Sr- <\o g{srsa-\Gcn . R.l-.irjo. 08-8 18-OO3/20 Susr\\" 1 P0rl-lCE Otr ARTERS, 0NCIJLE'523 002 ' ..r 0.N0. 35"1 {31551 3), lt,. i ,, " uk Cell: 9985336574 Form 26 (See rule 4A) AFFIDAVIT TO BE FILED BY THE CANDIDATE ALONG WITH NdumaTIoN PAPER BEFORE THE RETURNING OFFICER FOR ELECTTON TO LOK-SABHA (HOUSE OF THE PEOPLB) FROM I5.BAPATLA (SC) PARLAMENT CONSTITUENCY (NAME OF THE CqNSTITUENCY) PART.A s I, Smt. JESUDASU SBELAM, Son of ABRAHAM, Aged 67 Years, resident ofBIt.Xo.3, Sai Apartments (Towers) 4th Line, Brundavan Gardens, Guntur, Gqntur District, (mention full postal address) a candidate at the above election, dohereby solemnly affirm and state on oath as under : 3',*rE .,fi;*- \ (1) I arn a candidate set up by the "INDIAN NATIONAL CONGRIISS" (xxnarne of the political party) / x*am contesting as an lndependent candidate. (strike out whichever is not applicable) (2) My name is enrolled in 93 - PRATI{IPADU CONSTITUENCY, A.P. STATE (Name of the Constituency and the state), at Serial No.592, In Part No.240. (3) My contact telephone number(s) is Motrile No.9868181113 and my e- mail id (if any) is email id [email protected] and my social media account(s) (if any) is/are (D Whatsapp No.9868181113 (iD Nil (iii) Nir (4) Details of Permanent Account Number (PAN) and status of filing o1' Income Tax return. S1.No. Names PAN The Total lncome shown in financial Income Tax Return (in year for rupees) for the last fir,e which the financial year completed last Income- (as on 31't March) tax return has been filed 1 Self ALSPS4793B 2013-14 (i) 19,82,7801- (JESU DASU 20t4-15 (ii) 18,2r,4301- SEELAM) 2015-16 (iii) 23,45,3501- 2016-17 (iv) 17,45,9101- 2017-18 (") 17,52,9201- 2. Spouse AELPS7359P 2013-14 (i) 25,86,3301- ( Sujatha 2014-15 (ii) 2,27,6101- Seelam) 2015-r6 (iii) 2,79,3401- 2016-17 (iv) 3,66,3601- 6 a\ -\re t 2017-r8 (v) 3,17,2501- + 6E- 'dPt HN + h^49- ..=I J.a HLiF (rf (i) Nit candidate is Nit NiI (ii) Nil Karta I Coparcener) ( iii) Nit (i") Nit (v) Nit 4. Dependent (i) Nil (ii) Nil Nil Nit (iii) Nit (iv) Nil (v) Nit 5. Dependent 2 (i) Nil (ii) Nit Nil Nit ( iii) Nil (iv) Nil (v) Nit 6. (i) Nir (ii) Nit Dependent 3 Nil Nit (iii) Nit (irr) Nir (") NiI 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 declare that there is no pending criminal case against me.
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