I ""' '\ r- 45AA 797147 (39~I 3f4+-il s~~'rTT1100 ISHA
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R Form 26 (See rule 4A)
~=:;:-- • BEFORE THE NOTARV PUBLIC, BERHAMPUR, GANJAM ~aT"\R~ FFIDAVITTO BE Fl,'LED BY, THE, CANDIDATE ALQNGWITHNOMINATION */... . * PAPER BEFORE THE RETURNING ,OFFICER F'oR ELECTI'oN ~ (\",~:~~HI0Y I ro THE l\_ffiMBER,OFPARLIAMENT (LOK SABRA) , \\?~~J;.t FROM 20-BERBAMPUR"CONSTITUE.NCY ~~ PART A J. " , . 1, SRI CBANI)RA SEKHAR SAHU, son of Late Bipra Charan Sahu, Aged 68 years. resr~nt of Bijipur M~in Road, PO: Berh~mpur- 760003,.PS: Gosamnuagam, DistrIct: ,GanJam, Odisha, candidate at the above election, do hereby solemnly affirm and state on oath aSlnder:- (1) [am a candidate set up by BIJU JANATA DAL (2). My name' is enrolled in AC-133, BERHAMPUR, at Serial No. 1021, in Part No. U6 (EPIC No. KDN2100725). (3), My contact telephone rmmber(s) is 9437072119 and my e-mail id (if any) is sah,[email protected].~,~ ~ present and my social media accouut(s) (if any) is no I " romlS I'"ar~~, ",:' ...",..... )Os account. CJ ~\j./(~ ~~ q,c> ( e~ # L 4" c ~ J I NOTARY, BRAHMAPUR (I .1 1 rvv---4\D"- ~...... __,.... ~v:,_.._. s.L._.~~ ..._...\. ~ ~r)LDTo <:. · ~. 5,~ 'JT.· 1 J ~LQ 201Q
I(RUSHNlt~HM~ , .' STMf.P ;. r.:. T r- \. K1SSA fI' ,'-
'. -"..-,_- (4) Details of Permanent Account Number (PAN) and status: of filing of Income tax return:
[The financial year Total income shown in for which the last Income-tax return (in Rupees) SI.No. Names PAN Income-tax for the last five Financial return has been Years (as on the 31$tMarch) filed Rs.2,40,000.00 (i) 2013-14 Self Rs3,15.,600.00 (ti) 2014-15 1. Chandra Sekhar AGCPS1705N 2017'-18 Rs.3,15,000.00 (iii) "2015-16 Sahu Rs.3,24,.OO.00O (iv) 2016-17 Rs.3,45,00O.00 (v) 2017-18 I (i) I t, (u) NA .2. Spouse Not Applicable (iii) (iv) (v) (i) HUF(jftbe t: (ii) NA 3. Candidate is Karta Not Applicable (iii) or Coparcener) (iv) (v) (i) P- (ii) 4. Dependent-I t\\A Not Applicable I (iii) (lv) (v) (i) (li) 5. Dependent-Z N4L Not Applicable Cw'.) (iv) (v) (j) (li) i--- 6. Dependent-S Nfr Not Applicable (iii) (iv) (v)
Note: It is mandatory for PAN holder to mention PAN and in case of no PAN, it should be dearly stated "No PAN allotted",
2
------.. (5) Pending criminal cases
(i) [ declare that there is no pending criminal case against me. (Tick this alternative if there is no criminal case pending against the Candidate and write NOT APPLICABLE against alternative (til below) OR
(0) The following crimlnal cases are pending against me:
(H there are pending criminal cases against the candidate, then tick this alternative and score off alternative (i) above, and give deta_ilsof all pending cases inthe Table below)
Not Applicable
Table
(a) IFm No. with name and address of Police No No No ~tation concerned (b) K:aseNo. with Name of No No No ~he Court (c) ~ection(s) of concerned ActslCodes involved give .00. of the Section, No No Nb e.g. Section ...... of IPC, etc.). (d) Brief description of No No No offence (e) IWhether charges have been framed (mention No No No ~SorNO) .(t) lIT answer against (e) I
above is YES, then give I No No No the date on which charges were fra.med (g) Wbether any Appeal/Application fOT revision has been filed No No No against the proceedings (Mention YES or NO) I crms h~lt~.1k~~._. lIP\q \\)\}J~ O~ NOTARY, BAAHMAP~\ M.l (6) Cases of conviction
(I) I. declare that I have not been convicted for any criminal offence. (Tick this alternative, if the candidate has not beeD convicted and write NOT APPLICABLE against alternative (li) below
OR
(U) I have been convicted for the offences .mentioned below:
(If the candidate has been convicted, then tick this alternative and score off alternative (i) above, and give details in the Table below)
Not Applicable
Table (a) ~aseNo. No No No (b) !Nameof the Court No No No (c) Sections of Acts/Codes involved (give no. of the No No No , Section, e.g. Section ...... of IPC,
etc.). ~ - I (d) Brief description of I offence for which No No No convicted (e) Inates of orders of No No No conviction (f) Punishment imposed No No No (g) IWhether any Appeal ~'as been filed against conviction No NQ No order (Mention YES OJ" No) (h) Ifanswer to (g) above is YES, give I No No No details and present .status of appeal ~ (6A) I have given full and up-to-date information to my political party about all pending criminal cases against me ahd about all cases of conviction as given in paragraphs (5) and (6).
[candidates to whom this Item is not applicable should clearly write NOT APPLICABLE IN VIEW OF ENTRIES IN SCi)and 6(i), above]
Not Applicable in view of entries in 5(i) and 6(i) above
Note: 1. Details should be entered clearly and legibly in BOLD Jetters. 2. Details to be given separately for each case under different columns against each item. 3. Details should be ,givenin reverse chronological order, Le., the latest case to be mentioned first and backwards In the order of dates for the other cases. 4. Additional sheet may be added if required. 5. Candidate is responsible for supplying all information in compliance of Hon'ble Supreme Court's judgment iuW. P (C)-No.536 of2011.
(7) That I give herein below the details oftbe assets (movable and immovable etc.) of myself my spouse and all dependents:
A..Detailsof movable assets:
Note: 1. Assets in joint name indicating the extent of joint ownership 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 Bank/Institution and Branch are to be given.
Note: 3. Value of Bonds/Share Debentures as. per the current market value in Stock Exchange in respect of listed companies and as per books in case of non-listed companies should be given.
Note: 4. 'Dependent' means parents, sorus), daughterts) of Ute candidate or spouse and any other person related to the candidate whether by blood or marriage, who have no separate means of income and who are dependent on the candidate for their livelihood.
Note: 5. Details including amount is to be given separately-in respect of each investment
Note: 6. Details should include the interest in or ownership of Of~s~~re acssets~. 4\ Fcrrns f drl O~.~ ,. ~, \U~o'? 5 NOTARY. erAn .II t;,""'u;?t .JMJ ~~~~ Explanation> For the purpose of this Form, the expression "offshore assets" includes, details of all deposits or investments in Foreign banks and any other body or institution abroad, and details of all assets and liabilities in foreign countries';
S. No. Description Self Spouse HUF Deponent- Deponent- Deponent- Chandra Sekhar 1 2 ~ Sahu i) ~ash in hand Rs. 86,500.00 Nil Nil Nil Nil Nil Kii) petails of deposit in 1. Andhra Bank Bank accounts (FDRs, S.B. AleNe. 0.11210.01100.0. Term Deposits and all Qo.6balance other types of deposits Rs. 1,474.0.0. including saving 2. State Bank of accounts), Deposits IndiaS.B. Ale with Financial No. 300.60.469;569 ~ompanies and balance Rs. iCooperative societies 2,695.00. ~d the amount ineach 3. Slate Bank of such deposit India S.B. Ale No. Nil Nil Nil Nil Nil 10.0.23822545 balance Rs.. 72,.10.3.76 4. Andhra Bank Ale No, 017210.100.0.70. 325 balance Rs, 5,217'.60 5. HDFCBank AlC. No. 5o.JQo.2712a42 44 Rs.25,o.o.o..Oo. I,iii) Details of investment in Bonds, Debentures/Shares and units in Nil Nil Nil Nil Nil Nil companies/Mutual I Funds and others and he amount. _. (iv) betails of investment in NSS Postal Saving, Insurance Policies and nvestment in any Nil Nil Nil Nil Nil Nil Financial instruments ~n Post offiee or Insurance Company Form'lP" t~~ and the amount _" "t'~l.MI\PlJi\(GM.l j'l)ti rMn, .... . 6
(v) Personal Loans/advance given .0 any person or entity jincluding. firm, I Nil Nil Nil Nil Nil Nil company, Trust etc.. and other receivables from debtors and the amount. I/vi) Motor IVeh:icles/Aircraftsl IVachts/Ships (Details Nil Nil Nil Nil Nil Nil IOfMake, registration number, Etc. year of
purchase and amount) ! vii) ~ewellery. bullion and 480 Grams Ivaluable thing(s) {give Worth Nil Nil Nil Nil Nil ~etailsof weight and ~s.15,26,OOO.OO [value) :Cviii) !Anyoilier assets such las value of Nil Nil Nil Nil Nil. Nil claims/interest I (ix) IGross Total value IRs.17, 16,989.76 Nil Nil Nil Nil Nil
B. Details of Immovable· assets:
Note: 1. Properties injoint ownership indicating the extent of joint ownership will also have to be indicated
Note: 2, Each land or building or apartment should be mentioned separately in this format
Note: 3. Details should include the interest in or ownership of offshvre assets.
S.No. Description Self Spouse HUF l)eponeJlt'l Deponent-2, Deponent-S
-'""' (i) lAuicuJtural Land Location(s) Nil Nil Nil Nil Nil Nil Survey number(s)
~ Area (total measurement in acres) Nil Nil Nil Njl Nil Nil
, _., Whether inherited I Property (Yes or No) No No No No No No
Date of purchase in Case IOfself- acquired Nil Nil Nil Ni] IProperty ~,- ilpa~~~
7 NOTARY. elq;HMI~?u~(m,~.1 Cost of Land (in case of purchase) at the time of Nil Nil Nil Nll Nil Nil purchase
~y Investment on the I
I 'land by way of pevelopment, Nil Nil Nil Nil Nil Nil construction etc.
I Approximate current market value Nil Nil Nil Njl Nil Nil
(il) lNon-Atrricllltural Land 1)Bijipur Road Location( s) [2) Bijipur Road Nil Nil Nil Nil Nil Survey number:(s) (self acquired)
iAFea(total measurement 1)33xlSfeet lin acres) ~)46x80 feet Nil Nil Nil Nil Nil
~'ether inherited Property No No No NQ No No :('Yesor No)
, Date of purchase in case 1)29.08.2013 jof self - acquired 12)23.03J 976 Nil Nil Nil Nil Nil property
~ I Cost of Land (in case of 1)Rs.l, 76,OOOf~ I purchase) at the time of 2)Rs.2,OOO/- Nil Nil Nil Nil Nil purchase
,__" ~¥ Investment on the I land by way of development, Nil Nil Nil Nil Nil' Nil construction etc: I
---. Approximate current t.onc-ere market value As per mark~t Nil Nil Nil Nil Nil val-ue ,_' (ill) Commercial Bulldinzs i(induding apartments) Location(s) Nil Nil Nil Nil Nil Nil -Survey numberf s) f orrns Par ~ .. .--... ~ ·Of~j ~rea (total measurement o~ Nil Nil Nil Nil ~OT~tBI' )'H\Wh.·~~U~ in sq. ft.) ~~ .1.) --8 - [Buik-up Area (total measurement in sq.ft.) Nil ,I Nil Nil Nil Nil Nil
Whether inherited Property (Yes or No) -No No No No No I No
Date ofpurchase in case ~f self - acquired Nil Nil Nil Nil Nil Nil property I
~ost of property (in case pf purchase) at the time Nil Nil Nil Nil Nil Nil of purcbase "
iAny Investment on the property by way of ~evelopment, Nil Nil Nil Nil Nil Nil construction etc.
Approximate current market value Nil Nil , Nil Nil Nil Nil
(iv) Residential Buildint!.s Resideatial I kincluding apartments) house.Bijipur Locationts) jRoad; Berhampur Nil Nil Nil Nil Nil Survey number(s)
[Area (total measurement j40x80 Nil Nil ~nsq.ft.) , Nil Nil Nil
Built-up Area (total j40x60 measurement in sq.ft.) Nil Nil Nil Nil Nil
Whether inherited I Property (Yes or No) No No No No No No
Date of purchase in case I, Iof self _.acquired Nil Nil Nil Nil Nil property Nil
Cost of property (in case of purchase) at the time , Nil Nil Nil Nil IOfpurchase Nil Nil
, !AnyInvestment on the , property by way of development, Nil Nil Nil Nil Nil Nil construction etc.
Approximate current narket value Njl Nil Nil Nil ,~••i1I.t~ N1foft i\S [~tVl)j P, " ~, p M-\t-..~\J1i lGM. 9 (v) pthers (Such as. interest in property) Nil Nil Nil Nil Nil Nil
(vi) trotal of current market I Ivalue of (i) to. (v) above One Crore Nil Nil Nil Nil Nil
(8) I give herein .below the details of liabilities/dues to. public fmancial institutions and governmenr-
(Note: Please give separate details ofname of bank, .institution, entity or individual and amount before each item)
,S.No.. Description Self Spouse HUF Deponent-I Deponent-Z Deponent-S
i) Loan or dues to lBank/Financial ~n.stitution(s)
I, Name of Bank or Nil Nil Nil Nil Nil Nil lFinancial Institution, lAmount outstanding, Nature of Loan I I I , lLoan or dues to. any other ndividualsl entity other fuan mentioned above. Nil Nil Nil Nil Nil Nil Namets), Amount outstanding, nature of.loan
Any other liability Nil Nil Nil Nil Nil Nil
IGrand total of liabilities , Nil Nil Nil Nil Nil Nil I'
Forms Pari: ~~ . \...-').: NOTARY, BRAHMAP~ lGM.l
10 (ii) Icovernment Dues: (A) lias the Deponent been in occupation of r YES lDues to departments' accornmodatioruprovided by the :(Pl. tick the ~ea1ing with Government Government at any time during the last appropriate accommodation. ten years before the, date of notification Ialternative) of the current election? (B) If answer to (A) above is YES, the following declaration may be furnished namely'- (i) The address of the Government accommodation; 2, TUGLOKROAD NEW DELHI PJN- 110011
...... - ...... (ii) There is no dues payable in respect-of above Government -accommodation, towards• (a) Rent; (b) Electricity charges; (c) Water charges; and
(d) Telephone charges as 00 21-03-2019 (date)
[the date should be the last date of the thirci month prior to the month in which the electio[] .s notified or allY date thereafter].
Note- 'No Dues Certificate' from the
agencies concerned In respect of .tent,
electricity charges, water charges and ~elephone charges for the above GoveJ11.lben
accommodarion should be submitted. ~
11 (i'ii) lOues to department dealing ~th Government transport Nil Nil Nll Ni1 Nil Nil (including airerafts and [helicopters) Kiv) ncorne Tax dues Nil Nil Nil Nil Nil Nil Self Spouse HUF Deponent-I Deponent-Z Deponent-S
(v) GSTdues Nil Nil Nil Nil Nil Nil vi) lMunicipaliProperty tax Nil ijues Nil Nil Nil Nil Nil (vii) ~y other dues Nil Nil Nil Nil Nil Nil viii) brand total of all Nil Nil Nil Nil Nil Nil Government dues (ix) Kvhether (JIlY other liabilities I are in dispute, ifso, mention he amount involved and the Nil Nil Nil Nil Nil Nil authority before which it is pending.
(9) Details of profession or occu.pation:
(a) Self SOCIAL WORKER
(b) Spouse EXPIRED
(9A) Details ofsource(s) of income:
(a) Self PENSION & HOUSE RENT
(b) Spouse EXPIRED
(c) Source of income, if any, .of"dependents, NIL
(98) Contracts with appropriate Government and any public company or companies
(a) details of contracts entered by the candidate NIL
(b) details of contracts entered into by spouse NIL
(c) details of contracts entered into by dependents NIL
'(d) details of contracts entered into by Hindu Undivided Family or trust in which the candidate or spouse or dependents have interest NIL (e) details of contracts, entered into by Partnership Firms ill which candidate or spouse or dependents are partners NIL
(f) details of contracts, entered into by private companies in which candidate or spouse or 9tf~~ dependents have sbare NIL . , -, 1 ~1)1,) .,,1'
12 NO fAtly, !lRAHjVlI\P~ . (10) My educational qualification is as under:
>- B.Se {rom Khallikote College, Berhampur (Ganjam) affiliated to Berhampur University'in 1971. .,
}> LLB from Lingaraj Law College, Berhampur (Ganjam) affiliated to Berhampur University in 1915.
(Give details of highest School I University education mentioning the full form of the certificate/ diploma/ degree course. name of the School /College/ University and the year in which the course was completed.)
Fonl15 Fart C,RI.M.3~ . ~ lV~~O;' NOTARY, BRAHMAPUr, <-'I
13 f
PART-B
(11) ABSTRACT OF THE DETAILS GIVEN IN (1) TO (10) OF PART - A:
l. Name of the candidate SHRI CHANDRA SEKHAR SAHU
~. [Full postal address ItllJlpur MaIn xoac, PU: Berhampur, IPS: Gosaninuagani, District: Ganjarn,
I Odisha, Pin: 760003. I [3. Number and name of the constituency and State ~O-Berhampur, Odisha ~. Name of the political Jarty which set up the candidate (0 erwise write 131m JANATA VAL 'Independent' )
~. [Iotal number ot pending cnminat cases Nil
KJ· rr otal Number of cases in which Nil oonvicted
17· IVear for which last IIotal Income PAN of Income Tax: Return filed Shown IA(JCPS 1705N '~Ull-HS a) Candidate ,-. IKs.:;,4),OOO.OO NIl Nll ~) Spouse EXPIRED ,-. c)HUF lNil Nl~ NIl
d) Dependent INil ,1'1111 I N}I 18. IUdails 91Assets and Liabilities (mclu
(b) Inherited assets !Nil ~6S~ (Total Value) ,Formspar~~~ 'np -- NOTARY, BRAHM ArI(JR (GM:\ 14 •
9. ~jabUitie$ (i) Government dues I,Total) Nil Nil Nil Nil Nil Nil
I I)i) lLoans from Bank, iFinanoial Institutions Nil Nil Nil Nil Nil Nil lAnd others (Total)
10. ~iabilities that are under dispute ,i) Govemmentdues Nil Nil Nil Nil Nil Nil I'Total) "ii) Loans from Bank, IFinanciallnstitutioDS Nil Nil Nil Nil Nil Nil , And others (Total)
11. Highest educational qualification: )- B.Se from KhaUikote College, Berhampur (Ganjam) affiliated. to Berhampurt UniversityIn 1971.
)- LLB from Lingara] Law College, Berharnpur (Ganjam) affiliated t(] Berhampur University in 1975.
'I'Give details of highest School !University education mentioning the full form of the lCertificate/ diploma! degree course, name of the School /College/ University and the year tin which the course was cornpleted.)
15 ,
VERIFICATION
I, the deponent, above named, do hereby verify and declare that the contents of this affidavit .are true and correct to the best of my knowledge and belief and no part of it is false and nothing material has been concealed there from. 1 further declare that-
(a) there is no case of conviction or pending case against me other than those mentioned in items .5 and 6 of Part 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 of Part A and Items 8,9 and 10 of Part B above.
Verified at Berhampur this the 21st day of March 2019 ~~~~ DEPONENT
Note: 1. Affidavit should be filed latest by 3:00 PM on the last day of filing nominations.
Note: 2. Affidavit should be sworn before an Oath Commissioner or Magistrate of the First Class or before a Notary Public,
Note:3. All columns should be filled up and no column to be left blank. If there is no information to furnish in respect of any item, either "Nil" or "Not applicable", as the ease may be, should be mentioned.
Note: 4. The affidavit should he either typed or written legibly and neatly.
Note: 5. Each page of the Affidavit should be signed by the deponent and the Affidavit should bear on each 'page the stamp of the Notary or Oath Commissioner or Magistrate before whom the Affidavit is sworn.
16 FORM2A (See rule 4) NOMINATION PAPER Election to the House ojthe People \ , ,\~Q
, \~~\ ~\'\ I Q'V Il ~\~ j. ~. \ ,\.0
STRIKE' OFF PART lOR PART II BELOW WHICHEVER1S NOT APPLICABLE PART I (To be used by candidate set up by recognised political party)
I nominate as a candidate for election to the House of the People from the ..k.9...:: ~;~.b.~ ..(?.~ Parliamentary constiniency. Candidate, ' name., -,c..h."'V'\.~J~ ~-.c.. (~~•.r.~~_. _ C' ...... ,._L~ a ther's,Im~eia FSF'Q8r,e bagd!.flnatlle •~ - I-.JL.O..: ~~~"
PARTll (To be used by candidate . OT set up by recognised political party)
We hereby nominate. as candidate fo election to the Rouse of the People from the , 'Parliamentary onstituency ... didate' F th 'I _th 1·lL. ba d' I Can nate's nam.e _ , " at ers rno erStllUS" ~_ 's oZ § nam,e Bis PQstal address.... .,..'," , . iii ... !' ~ ••••••••••• ' ' .. .~ 1 'r0 ...~ ofthe His name is e.,tered at S.No ..,.· iti Part No ···············.. · electoralrollfor ...... •...•...... :.. '(Assembly. -' -llonstitue)lcy' eotnpriSed' wiihilt) ...... : :..ParliaInentary' constituency. ~l I We declate that we are electors· .J the above Parliaroelil'taty CqnstitUencyand our name~·are entered 1m the electoral roll for tha .Padiamen!:alY Constltoe)lty a. ,:indicated below and we append our signatures below' intoken· f subscribing tothis nomination:-. .
partlClilan of th prQPosen and 1heir-mgn.tures Date Name of Elector· . oUNo. of Full Name Signature *1 f S1.no. , • I wbi' cpmponent , Pro to... Assembly Part·No. of • 1 Constituency Electoral gen Roll 7 5 IDO 1 2 3 1. 2. Dc 3. .._...... - 4. "'s S. .: K 6. I •. a' 7. -, *,. S. ~., -a
9. (; 1 10'. N.B'.-Th~re should be ten electors of the cOnstituency aspropcs .. t-tc9- vr~~ ~b52..A pA-RTm I,the candidate mentioned in'Part lJPart II (Strike out which is not "PPli<:able) assent to
thls nomination and hereby declare- Ca) !hat I am a ~i~en of Inota and have not acquired the citizenship of any foreign
State/country. I (b) that I have completed ~ ~ years .of'age; [S'I1UKEOUT c(i) or c(u)BELOW WHICHEvER 1SNOr APPLICABLE] (c) (i) that Iam set up at this election by'tbe .....!Pi:J.f,oL.:r fl:H .1'1.1.I.\...I).l\: f..c pilI\Y, which is a reW~ 1>Iatill""ll'aoij'/Stale Party m:" this'Stale and that the symbol reserved for the above pal1y be allotted to me. .... OR
2 :.t (c) (ti).that 1 am!set up at this.~lection the . party, which is a registered- . ecognised political party/that Iam contesting this election as an jndependei ,·Candidate. (Strike outwhieh is not applicable) and that the symbols I have ch n, in orderof preference,are:- (;) (il} ~...... •..... ,., (iii) ; , · . (d) that my n~e and my fatliets/mother'slhnsband's name have been correctly spelt out above in ....t-;.c~·.b.h-.....(name of the language); (e) that to the best of my knowledge and belief; I ani qualified and not also disqualified for being chosen to fillthe seat inthe House of the People.
*1 further declare that I am a memQerrf th : .t: ::.:': ,.., : ·!I<·Caste/tribe which is a scheduled •• caste/tn.'_be ,of tile S te of. ' : inrelation to ,.., {area) m that S ." . I also declare that I have not been, and shall not be nominated as a candidate at the present general election/the bye-elections being held simultaneously, to the House of the People frem more than two Parliamentary Constituencies, .
~~~~~~ Date 2\--, O~- .")..ol9 Signature of Candidate "
TScQre out the words "assembly constituency comprised within" in the case of Jammu and Kashmir, Andaman and Nicobar Islands.•Chandigarh, Dadra and Nagar Haveli, Daman aad Diu and Lakshadweep. *Score out this paragraph. if'uotapplicable.
11< • Score out the words not applicable. N.B.-A "recognised' political party" means a' poEtical party recognised by tbe Election Commission under the Election Symbols (Reservation and Allotment) Order, 1968 in, the $)ate 'concerned.
"
PARTDIA (To be filled by the candidate) (1) Whether the candidate• (i) has been convicted- (a) of any- offencets) under sub-section (1); or (b) for contravention of any law specified insub-section (2)" of section 8 of the Representation of the People Act, 1951 (43 of 1951); or ~JN0 (it) has been convicted for any other offence(s) for which he has been sentenced to imprisomilent for .two yearsor more. 3 • of •~n)l If the answer is "Yes'), the candidate shall furnish the, following information: Goverr (/) Case/first information report No./Nos f':-:{ ~ p.~,rf. 'p.t"~t;:~.~~ -tf Yeti ( '1'\ P li . .'. (s) r-: I 9- A- L.. /....0 • (....c;>.LQ...e.. II) 0 Ice station S ~~CF. .•••• ~n\':q-:-~ ~. .~...... DistrJct(s) .- _.' State(s) _ " _., " .. )Wheth~ (iii) Seotionjs) of the concerned Act(s) and brief description of the offenoe(s) for which be CorpOl' has b - -. . t ·a I.._ f,. (J_ A-LL...t,c._..::._.(_ ~ . .een conVlO.e 1'''""'-"...7. ••• " .f'1.V..,v. '•. """ 0 , . Goverl (lv)~~~(~)~f' ~~~~i~ti~~(~)~~~~~~..t;j~.'~:; ·'Ii ~~~'i ~.~ . \{pfn 9.~.~ -IfYe
ev) Court(s) which convicted the candidate ~.~.f:: r:thk~·;~E>k ~ ...... - ... (vi)Punisbment(s) imposed [indicate period of imprisonmenus) and/or quantum of '9) Whe.( fine('S)] .... ,..... h(~.9.:.~..tt.~t.-tr~~. b L.. saidJ (V1',~1'\/'Date('S.y- 0f re~leasee fr'._,om pn'so, ',un l, \e.t!., ,.IflJ-..r,L.y..1.. ~ 'a-.. "-i:.J. -If ye (vUl)Was_/were any appea1(s)/tevision(s) filed against above convictioms) '., ~~o . (ix) Date and particulars of appeat(s)!appiicatioQ(s) for revision filed ,. , ...... :~~?:-...A:J.. kq.;,"~ b~ Place: . (x) Name, of the court('s) before which the ~ppeaI(s)/app1icatlon(s) for revision filed . Date: .' ...., ~~~~:...'~tr.£t.,~,r.,iL. (Xl} Whether the said appeat(s)/application(s), for revis'ion haslbave been disposed of or I.S/.are pen. ,d',mg· 1;:"_r."~11., ,. V1~ rLLr' t." c..-.t,JL. (Xi'l}If the said appeal(~)lappJj'cation(s) for f~vision Iru~slhavebeen. disposed of• Serial, ' (-a) Date,(s) of disposaL .... .(~~!":.~7... (.f:.F.~~. :~c....L-. (b) Nature of 0rder(s) passed ... t:-:-f..'t-.l•. ..t:f:1t:.~.~!L- on..~\ (2) Whether the candidate- is:holding, any offioe of profit under the Go:vemment of India or State Gov,ernment? ...... (~1N.o) , -If Yes, details of the office held l~ ,c? ....•...... •.....•• , ..••. _... (3) Whether the candidate has been declared insolvent by any CbUrt? ~/No) Date. ~IfYes"has he b~ discharged from IDS'olvency , . (4) Whether the cap,didate is under aUegianGe or .adherence to any fureign country? ...... -.~slNo) -If'Yes, give details .- , .. (5) Whether the candidate has been disqualified under section 8A of the said Act by au order of Rep the President? ....t:U?...... , (YIS/No) -If Yes, the period for which disqualified ' ',' '" , .
(6) Whether the candidate was dismissed for corruption or for disloyalty while holding office 4'" .. under the GOVeniment of India,or the Govemment i:>fanyState? .~.l.9...(Y~lNo) -If YeS, the date of.such di_smissal. ~R _ (7) Whether th.e candi4ate .has any subsisting contract( s) With the Government either in iildividwu capacity or by trust or partnership in'which the candidate has a share for supply 4 of ~ll-y goods to that Government or for execution of works undertaken by that Govemment?.N.t?. ... c:yJ.1N0) -lfYes.~with Which Govemmenr ana details oi's,y-psisting contract(s) ' _ ...... , .,'...- ~tCl ,;. ;.,.'10 " •.•: _ . ,. ) Whether the candidate is a managing agent, or manager or Secretary of any Company Of 1. fcb he Corporation (other than a cooperative society) in the capital of which the Central GOvernment or State Government has not less than twenty-five percent share? ~. 11···,··r· ...... (Y.,esIne) (,t CJ ~ -If Yes, with which Government and the details thereof t:·{.~.., ' _ .. J , _,,' . of (9) Whether the candidate has been disqualified by the Commission under section H)A of the said Act. .. ;..t-:\;~ (Y~tN 0) -If yes, the date of disqualification...... •... N.a .
• <._•••• v ~ ~ J-VfJ4-.?~ Place: ..<;~. ~Fu....._ Signature ofCandldete Date: .. ,.:5,.~.-:'~.3.-')..0 ~~ or PART IV .' . . . .' (To~tfiUedby the R~~t?fficer) I Serial No ..ofnormn.aho~ paper .•...... J~~..l·l.Q.)~-t-.R , ' , _. , 10 fM . I ,~s- nomination was ~vered .to me at my office at. (hour) '( on.~~\.t-:s..,1P.~'..(date) by the "can.didate/pro~T' (name of proposer ...... )
Date , .
PARTV Decision of Returnlpg Officer Aeeepttag or Rejedjng the Nomination Paper 1 have' examined this nomination paper in aeoordance -.r~th section 36 of the Representationof the People Act, 1951(43of 1951) and decide as follows:-
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.. .. OJ ~ " ' ~ .. ~ ' , * 01- '0 " ;. , , 0'" , , !' ' i ..
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Date . Returning Otlic$t i _-._ ,.., (l'erfora;iOU) - _ _ _._ _ .. PART VI Receipt for Nominatiol;l raper and Notice of Scrutiny .(To be bandedover-to the~onpreseIitingthe Nomination.Paper) { papec. SerialNo. of nomination . ··r · ·...... J' . ( The nominatior» paper of. 8 candidate for election from the...... •...... n •••• Par.li.~entary constituency was delivered to .me at my office at...•...... (hour) on (date) 'b.y the ~candidate!proposeI. All nomination papers will be taken lip for scrutiny at , :(hour) Ol!l , ~(ch\te)at.. "...... (P~).
L>ate .. Returning Officer
·ScOre out the word llQt applicable.
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