U,"2\11.1:"'"'*" Noiuination PAPER Electk,L to Th

$U,"2\11.1:"'"'*" Noiuination PAPER Electk,L to Th$

.-t'"u,"2\11.1:"'"'*" NOiUINATION PAPER Electk,l to th. Hauvafthe People

}AIIT II (To be ued by cand nreNoTser upby

nomimle rs candidale lir cLctior ro rh. Ho$o of rhe Peopb nlm Pa ilLne.r }Con(itueicy I Hisnameisenle.edars.No...... inPlrrNo...... o1rheelectoraltul]tor ...... r(Ass.frbtl con(iruencr compriscd wirhin)

...... parLiamenrar] consriruenry.

we dccl.rc rhat Ne are elcctoE ofthe obole P.rlidncntdo Constnuefty and ou names ore entered in thc electoral bll ror thal Plrlilmenrar! Constituency as indic.lcd tElow aid *e

PART DT l. rhe candidare rncntioned io prrt t,/ps't tl(Srdke od $hich is nor appticable) aser lo rhG horniir.rion and hercby de.la'e (a) drlr I amacni2co ollndiaand h.vc mtacquned fie ciiirNhipolafy tnEiEn V itr (hotl have..n,nleted . ....6-l.... ""v"'"oL'g"' '"' "iir.*t-ijilr;ll*r")(ii)seLorvwHtcusven rsNorArPLlc'\BLEI -tl-e 4..?/--a-.... l5m \eI up n rhs L c'rm b\ rhe " 'i4' " ''aq .'''.P lcrr/rrtLr oJ'rle .'"i." ."re.'r " o !d:41 Pi\ 5rJ': f l)'r'h''S'a"1' "", iu ne --i", **^.a r.,,n",r.o'. 0.tr1\ be allorrrd OR le "" - ,.,,r' ' rl, lsF"cr'..-"'1.,".r-.o ''. Jr' "" rrc. er.aP 'i'" 'r'' '\"' 'es..'p'''

th. smboh I hrw7choscn, in order'l pttlcrere rrer- (i).. (,i) ...... " " lr") slch out (":l1iJl',,:1r;-li rn! larher's/morhers/hrsbands orhc hare bcen coircclly li4...... (mrne olthe lansurec):

qualined and nol iho dhlldalificd (c) rhd o the ber olm) krc$l'd-ge and beliei I am tbr bcin! chosen ro []lthe sed intheHouse C**be1+)-.. {*c"ner**,e 1l turrhcr dcclnrc thar I an a rncmbc'of the' s.r.q4tJeJ-. erco$e/tribe .. ... in rc!arion \hi.h is a scheduled ol ihe State .r ...... r<.gel:....Gs.-*-i.+]..:.

@mumd aM Diu -"",;;il;;;;";Ni"J", kr.nds. cilaidilarh Dadm and Naarr ttav'li' Darnan

lscoreout dris p.ragmph. ilnor dtpliclbl'' .+s..rco nre \rordsn.r applicablc prii) rccognh.d br_ the Eleclion N B.-A Lcco!' F.Ll poli' nrr\' mcin\ J polnirrl 'r Ordct 1963 nl the stdc cominbsu, r ri* rlt Els' un SJmbols lRrser onJnd Allouncno ,

T RT IIIA I obefiledb) '.3 dd, el (l) she(herthe candidaLe - (i) ha been.otrlided - G) otaryolienc(s) urd sub secrlon (l)ior : pc! .r 'bi lo' !o'.'..e",or of 1\ I \. leJ'i b-,e!rio, ilL c' . 'i,. q " r R.p e. fl E .. , r ' , . o .opl . A. ' ' o.r\o (ii)has becn conricrcd 6r anr orh.roffcncc(t for which hc has bccn semenced ro inprisonmcnt lbr t$! ) eats or morc.

,., -^- ',' ,' ,t, , ,. ,, (v) counG) \!hich coovlcrcd rbc -di 1 ...... |{Jl. }r"4<.r1,&...:...... {vi) Punishmcn(, mposed []ndiclie pcrodori'nprisonment(, and,rorquantumof nre(s)1...... ^.'.1..rPPqe-.!f:..1... (vli) D,te(, orrclease from p,isor...... 4,e!....7:,4/1.i*!(..: (viil)$ls/rvcrc iny appedlG)/turlionG) riled againn above convi.lio(r&t.+fi*4Y6nlo (ir)DateandprnicularsorapperLG)/applicariooG)turrlisi.nfi]ed...... N?a.-1iP9*4t : .... (r)\arneolthecoM(rb.ftrc\rhi.hlheappealG)/applic.rion(9lorrevisionfiled...... !!..1...*p&t -.kl ...... (ri) \\,hcthe.a1e saidappeal(s)/anplicarionG) lorrevisiorha!/have beEndisposcd olor n/arc pendinP.... .!.a' -Le\' (xii)Irthesxidappel(rhpplication(s)forrevisionhas/ravchf.ndkposed.r-^PF,l;. . (d) DaleG) of disp.saL...... aa-q,. . ?H&.*L!,

(b) Nilrc or odc(, pa$ed...... 1t. i.!. . *p*.+-){- . (2)\Lhcthc.th..andidareishoLdin!anyolfireolpronturderlhccovcrnnrcdoflndiaorStale cove, n,nox?..+l!:: (Ya^o) -rryes. detarr' of trrc oflice held.. . . L? i..4f ig:.a-B\ : ...... (r) \\'hcrlrer rhe caMiJatc hasbeend.darcd ids.lv. by rny coun? ..i!s.,. (Y.s^"o) lrYcs.hishdbccndisch sednominsolveno)..4t(.4PAcJ(' i4) \\hcrhcr the rJrJ drc n undcr Jlelirn(c

. .. rf Ycs. -{ive delairs . at?. .41.&e:lt. *. ... (5) \!hether lhe caididatc h.s bcen disquolilied under scdion 3A ofnrc sald Act bi_ an ordcr ol rhe Presidcnr?.....^.'! :... (Y.s^\o) .lr\e..r'ere,i rl rl .r Jr{r.J.'fj,l .ryc' +r{ ^^ . . 16) $helh{lhe candidatc was disfrnsed lor c.irnntion or ior dinoyall) \hile holdtus orfi.e under ihe Colemm.nr orlndia or rlrc co\snNcnt ofan, Sr&e?.....43- .(yesNo) rrYes, rhedateorsuch disn,hsat.. . l:!1. !f*..-at" (7) whcthcr llr.xndi.Lite has iry subslsling cont,ac(t \ith $e ColeLnment eirher in ildividual coplcirr or bj- kust or panrctship iD \hich dre candidat. hxs x share lor srp|l) oT.nr go.dsrolhat Colearmeiror lor execur on ol\ork\ undeitkcr b) thal Coretument?

-lrYcs \ithshi.hGo\cnnncntanddetalsofaLbsnli'rgcontraoir..... -

(3) candidate h n ,n$aging agcnt. o.ma.agerorSccrct$yoaai) compan) or (olherrlmnacoopcrar!esocleq) intheclpnalolshichrheCentral 'r Su!. C!\ennD., i irir d.n le$ ti t\cnl!n\. Pe..crt sl'r,r?. ..|:i.. Nhich Goremmenr .nd the details Lh(dor... ..{.1.1.. +liq+#1.

(9) Whcthcrrhe candidale has bcendhqualificd bl the Commissionrnner section l0A oldt Mid Ad...... 1!.r.. ... f/4'r.) . -, Il!cs. rhe d.te olJisquaLificarion !'{at t*Pqaj!*: , C'."^r-' A" P..t-"

t AllT tv (To benl]ed b] the RellLnine Om.cr) serial No. orDoNif ation papcr ...... -,9.:4.lt t-..t 2olstRo Ms delileEd io nre al rhc lcrnJ idxte/ !o!.*i (nxfre of

n". 19 .0I 2019 Retumin4 offcer'

Parlid..bry ConstnDencY

P q Ernm WEST BENGAL vl o Regd hlo.' \9 x--..-zo.q ?rwedrY Form-26 (See rde aJf)

ATTIDAVIT TO BE FITED BY THE CANDTDATE AI,ONGWITH NOMTNATION PAPER BEFORE THE RETt'RNINC OT"ICER FOR ETECTION TO TOIGABHA (NAME OF THE HOUSE) FROM l COOCH BEHAR (S.C) PARLIAMENTARY CONSTITUTENCY (NAME OF THE CONSTITUENCY)

PART A

I, GOBINDA CHAITDRA RQY. son of LATE SARBAI{flI{DA ROy Aged- 6t years, resident of PATHAGAR UINE. PAIIDAI'AIUI ROAD .P.S. KOIIIIALI. P.O, & DIST. JATPAIGURI. PIN- ?35101 (mention full postal address), a candidate at the above election, do hereby solemnly affirm and state on oath as under :-

(l) I am a candidate set up by AtL INDIA FORWARD BLOC. (**name of the political party) /** am consisting as an Independent candidate. (** strike out whichever is not applicable) (2) My name is enrolled in l7 JALPAIGURI-.(S.-C) 4.9. W,B (Name of the Constituency and the state), at Serial No. 4!3-in Part No. 140 .

G=fips/? Errttr Saratht Dcb B.Cos'tLl NOTARY W No.-2 lGlighat Rg.d Cooch let16c \&flB. Rcgd.Nq- tE/2O{r7

I -' }t-;-'na} c: Starnp LLndo.. L*^.n --t€,14{ Llenc. ',o -7212'&tiq \ tr..

I ;.""'#,ft$ :s$e,

t3) My contact telephone number(s) is 9434@0668 and my e-mail id (if any) is [email protected] and my social medla accounts ( if any) is/are (i| Whatsapp - 9434000668

(4) Detail of permanent Account Number (PAN) and status of filing of lncome Tax return :

Sl.No. Names PAN The financial Totalincome year for which shown lncome-Tax return (in the last lncome- Rupees) for the last five Tax return has Financial Years completed been filed (as on 31't March) L. Self (i) Rs.7,12,010.fl1 (2013-14) (iil Rs. 7,17,012.00(201+15) GOBINDA CHANDRA ROY ACKPR3121K FINANCIAT {iiil Rs.7,22,010.fi!(2015-16) YAEAR.2OTT (ivl Rs. 8,1Q332.00(201e17) to 2018. (vl Rs.8,91,487.00(2017-18)

2. Spouse "No PAN NOT APPLICABLE (r) NOT APPLICABLE SABITA ROY allotted" (ii) NOT APPLICABLE (iii) NOT APPLICABLE (iv) NOT APPLICABLE (v) NOT APPLICABLE

3. HUF (lf Candidate is NOT APPLICABLE NOT APPLICABLE (i) NOT APPLICABLE

Karta/Coparcener) ( ii) NOT APPLICABLE (iii) NOT APPLICABLE (iv) NOT APPLICABLE (v) NOT APPLICABLE

4. Dependent -1 NOT APPLICABLE NOT APPLICABLE (i) NOT APPLICABLE NOT APPLICABLE (ii) NOT APPLICABLE (iii) NOT APPLICABLE (iv) NOT APPLICABLE (v) NOT APPLICABLE 5. Dependent-2 NOT APPLICABLE NOT APPLICABLE (i) NOT APPLICABLE NOT APPLICABLE (ii) NOT APPLICABLE (iii) NOT APPLICABLE (iv) NOT APPLICABLE (v) NOT APPLICABLE 5. Dependent-3 NOT APPLICABLE NOT APPLICABLE (i) NOT APPLICABLE NOT APPLICABLE (i i) NOT APPLICABLE (iii) NOT APPLICABLE (iv) NOT APPLICABLE (v) NOT APPLICABLE Note : lt is mandatory for PAN holder to mention PAN and in case of no PAN, it should be clearly stated "No PAN allotted".

B.Com LLB NOTARY No.-2 Kalighat Floed Cooch Behar, W.B. Regd. No.- 1AI2OO7 sfr#q

(51 Pending criminal cases is no criminal (i) I declare that there is no pending criminal case against me. (Tick this alternative if there (ii) case pending against the candidate and write NOT APPLICABLE against the alternative below)

OR (ii) The following criminal cases are pending against me :

of (lf there are pending criminal cases against the candidate, then tick the alternative and score alternative (i) above, and give details of all pending cases in the Table below)'

Table dt. NOT APPLICABLE (al FIR No. with name and FIR No.157/13 dt. FIR No. 593/12 address of Police Station 31.01.2013 25.09.2012 concerned P.S. Koturall, P.S. Alipurduar Jalpaiguri

Case No. NOT APPLICABLE (bl Case No. with name of the 6.R Case No. G.R Court 4641L3 21991t2 Ld. c.J.M - Ld. A.C.|.M - Jalpaiguri Alipurduar

NOTAPPTICABLE (c) Section(sl of concerned uls-4o9lt2oBof uls-42ol40i0l40el lPc. Acts/Codes involved give no. rPc 46A147t of of the Section, e.g. Section...... -.... of lPC, etc.) Cheating and NOT APPTICABTE (d) Brief description of offence Criminal breach of trust by Public dishonesty inducing servant or bY delivery of banker merchant or property, agent, Punishment Punlshment for for crimlnal criminal breach of conspiracy trust, criminal breach of trust bY public servant or bY banker merchant or agent, forgery for the purpose of cheating using as genuine a forged document or electronic record NO NOT APPLICAEIE (e) Whether charges have been NO framed (mention YES or NO) APPTICABTE NOT APPLICABLE (f) lf answer against (e) above is NOT APPTICABTE NOT YES, then give the date on which charges were framed NO NOT APPUCABLE (g) Whether anY APPeaUAPPlication NO for revision has been filed against the proceedings{Mention YES or NO) @fls p;*m'C,gr W {6) Cases of Conviction I declare that I have not been convicted for any criminal offence. (Tick this alternative, if the has not h\(t" been convicted and write NoT APPLTCABLE against the t alternative (ii) below)

9'g-'sT,i#q OR been convicted for the offences mentioned below : ndidate ."$$y has been convicted then tick this alternative and score of alternative and give details in the Table below)

Table (a) Case No. NOT APPLICABLE NOT APPLICABLE NOT APPLICABLE (b) Name of the Court NOT APPLICABLE NOT APPLICABLE NOT APPLICABLE (c) Sections of Acts/Codes involved NOT APPLICABLE NOT APPLICABLE NOT APPLICABLE (give no. of the Section, e.g. Section ...... of IPC etc.) (d) Brief description of offence for NOT APPLICABLE NOT APPLICABLE NOT APPLICABLE which convicted (e) Dates of orders of conviction NOT APPLICABLE NOT APPLICABLE NOT APPLICABLE (f) Punishment imposed NOT APPLICABLE NOT APPLICABLE NOT APPLICABLE (e) Whether any Appeal has been NOT APPLICABLE NOT APPLICABLE NOT APPLICABLE filed against conviction order (Mention YES) (h) (g) yES, lf answered to above is NOT APPLICABLE NOT APPLICABLE NOT APPLICABLE give details and present status of appeal

(6Al given I have full and up-to-date information to my political party about all pending criminal cases against me and about all cases of convlction as given in paragraphs (5) and (6) .

I Candidates to whom this ltem is NoTAPPLICABLE should clearly write NOTAppLtCABE tN VtEw oF ENTRIES lN 5(al AND 6(il, abovel

Note: 1. Details should be entered clearly and legibly in BOLD letters. 2. Details to be given separately for each case under different columns against each item. 3. Detalls should be given in reverse chronologlcalorder, i.e. 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 in W.P(ClNo. 536 of 2011.

(7) give That I herein below the details of assets (moveable and immoveable etc.) of myself, my spouse and all dependents. A. Details of movable assets:

Note: 1. Assets in joint name indicating the extent of joint ownership will also have to be given. Nqte: 2. ln case of deposit/investment, the detalls including serial Number, Amoun! date of deposi! thE scheme, Name of the Bank/lnstitution and Branch are to be given. Note : 3. Value of Bonds/share Debentures as per current market value in stock exchange in respect of listed companies and as per books in case of non-listed companies should be given. Nqte :4. 'Dependent' means parents son(s), daughter(s), ofthe candidate or spouse and any other person related to the candidate whether by blood or marriage, who have no separate means of inqome and who are dependent on the candidate for their llvelihood. 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 offshore assets. w1,if NOTARY No.-2 Katighat Road Cooch tsehar, W-8. Regd. No.- 1A/?-coi .u-*L'@ :t#>

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';

sl. Description Self Spouse HUF Dependent-1 Dependent-2 Dependent No. -3

(i) Cash in Rs-20,000/- Rs- NOT NOT NOT NOT hand 7,0001- APPLICABLE APPLICABL APPLICABLE APPLICAB LE E (ii) Details of Union Bank- Central NOT NOT NOT NOT deposit in JalpaiguriBr. Bank of APPLICABLE APPLICABL APPLICABLE APPLICAB LE bank sB- lndia, E accounts 5740201000 Kadamtal (FD Rs. 4425 a Branch, Term Rs. 12,000/- Jalpaiguri Deposits SB-(Pension SB- and all A/c) 32693039 other types 5286020300 28 of deposits o2732 Rs. including Rs.2,800/- 32,OO0/- saving sB- account). 5286020100 Deposits 27005 with Rs.5,000/- Financial FDs- (Union institutions Bank) ,Non - 458809 Banking Rs. 15,000/- financial 5286020SCS Companies s000098 and Rs. Cooperative 14,00,000/- societies sBt- and the Jalpaiguri amount in Town Branch each such sB- deposit. 20L38632L7 3 Rs. 10,000/- SB- (Ex- MtA Pension) 3777t56627 o Rs. 11,000/- Gq,, Partha saiathi Peti B'Com LL'B NOTARY Road Nci.-2'Cooch Kalighat tsehar' WB' n-ugJ No.- 18/:2on- bt"@ ,g"*} "t("$ff

(iii) NOT Details of NOT NOT NOT NOT NOT APPI-ICABI.E APPI.ICABI.E investments APPTICABLE APPLICAELE APPLICABI.E APPLICAB in Bonds, LE debentures. shares and units in companies/ Mutual funds and other and the amount

(iv) Details of {a)LlC Policy (a)Llc NOT APPIICABIE NOT NOT NOT investments no.4519962 Policy No. APPLICABLE APPLICABLE APPLIC in NSS, 96 40206083 ABtE Postal SA 6SA Savings, Rs. Rs. lnsurance 2,0o,ooo/- 75,OO0/- policies and (b)Nsc- (b) Lrc investments 39EF858744 Policy any financial Rs.10,000/- No.45645 instruments 7t42SA in Post Rs. office of 50,000/- lnsurance companies (c) LIC and the Policy amount. No.45619 4185 SA Rs. 1,25,0O0/

(d) Lrc Policy No. 4562t256 2 SA Rs. 30,000/- (e) Llc Policy No. 45545325 2 SA Rs. 40,000/- ,Lq (v) Personal NOT NOT NOT NOT NOT NOT Loans/adva APPLICABLE APPLICAB APPLICABLE APPLICABTE APPLICABIE APPLIC ABLE ata!" nce given to LE t-$'l-s ,t a any person raa#d ) or entity ,Y{ including firm. ${,ffi. Company, c Trust etc., S.,,"sy ') 'L* (__ + t If!.s.*.P*?fe '>'e.di*.*l -N*S4c"gf#r?ffi K.-i6, and other receivables from debtors and the amount

(vi) Motor NOT NOT NOT NOT NOT NOT APPLICABLE Vehicles/Air APPLICABLE APPLICAB APPLICABLE APPLICAB APPLI craft/Yachts LE LE CABLE /Ships(Detai ls of Make, registration number etc. year of purchase and amount) (vii) Jewellery, NOT Gold NOT NOT NOT NOT APPLICABLE APPLICABLE APPLIC APPLICABLE Jwellery APPLICABLE bullion and ABLE valuable 30 gm. thing(s) Value Rs. (give details 1,00,000/ of weight and value)

NOT (viii) Any other NOT NOT NOT NOT NOT APPLICABLE APPLICABLE APPLIC APPLICABLE APPLICAB APPLICABLE assets such ABLE as value of LE claims/inter est NOT NOT NOT (ix) Gross Total Rs. Rs. NOT APPLICABLE APPLICABLE APPLIC APPLICABLE Value L6,85,800.00 4,5g,OOOI ABLE

B. Details of lmmovable Assets :

Note : 1. Properties in joint 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 offshore assets.

-3 Sl.No Description Self Spouse HUF Depend Dependent Dependent ent -1 -2 (il Agricultural land NOT NOT NOT NOT NOT NOT Location(s) APPLICABLE APPLICABL APPLIC APPLICA APPLICABLE APPLICABLE survey number(s) E ABLE BLE

'(.{)ot Area(total NOT NOT NOT NOT NOT NOT g' measurement in APPLICABLE APPLICABL APPLIC APPLICA APPLICABLE APPLICABLE $\). E BLE -"4 ABLE 'qIaa, ' r\' c acres) f,:Av f$ +"a.Y9,;,$-ij$$ l^".Y,v t2 +o.P'8: ti,$r^ \- Whether inherited No No NOT No NOT NOT property or not APPLIC APPLICABLE APPLICABLE (yes or no) ABLE

Date of purchase NOT NOT NOT NOT NOT NOT in case of self APPLICABLE APPLICABL APPLIC APPLICA APPLICABLE APPLICABLE acquired property E ABLE BLE

Cost of land in NOT NOT NOT NOT NOT NOT case of purchase APPLICABLE APPLICABL APPLIC APPLICA APPLICABLE APPLICABLE at the time of E ABLE BLE purchase

Any investment NOT NOT NOT NOT NOT NOT on the land by APPLICABLE APPLICABT APPLIC APPLICA APPLICABLE APPLICABLE way of E ABLE BLE development construction etc. Approximate NOT APPLICABLE NOT NOT NOT NOT NOT APPLICABLE APPLICABLE APPLICAB APPLICABLE current market APPLIC LE value ABLE

(ii) Non-Aericultural Mouja-Kharia Mouja- NOT NOT NOT NOT Land L.R Khatian Kharia APPLIC APPLICA APPLICABLE APPLICABLE Iocation(s) : No. 17135 L.R ABLE BLE Survey number(s): Khatian No.179 Area (total 3600 sq.ft. 2to5 NOT NOT NOT NOT measurement in sq.ft. APPLIC APPLICA APPLICABLE APPLICABLE sq.ft.) ABLE BLE

Whether inherited No No NOT No NOT NOT property (Yes or APPLIC APPLICABLE APPLICABLE No) ABLE

Date of purchase Dated- Dated- NOT NOT NOT NOT in case of self 27-LO-2006 27-tO- APPLIC APPLICA APPLICABLE APPLICABLE acquired property 2006 ABLE BLE 11-11- 20Lt Cost of land in Rs.4,00,0ffi/- Rs. NOT NOT NOT NOT case of purchase 2,OO,OOOl- APPLIC APPLICA APPLICABLE APPLICABLE Rs.1,08,840 the ABLE BLE at time of t- b purchase ,ffi-"? 9. P,s."fi,fB G$f ffiri:#.,y,

NOT NOT NOT NOT NOT APPLICABTE APPLICABLE Any investment APPLIC APPLICAB APPLICABLE NOT APPI-ICAETE LE on the land by ABLE way of development, construction etc. Approximate Rs.5,00,000/- Rs.4,00,000 NOT NOT NOT NOT /- current market APPLIC APPLICA APPLICABLE APPLICABLE value ABLE BLE (iiil Commercial NOT APPLICABLE NOT NOT NOT NOT NOT APPLICABLE APPLICABLE buildlnrs APPLIC APPLICAB APPLICABLE LE (including ABLE apartment(s)- Location(s) Survey number(s) Area (Total NOT APPLICABLE NOT NOT NOT NOT NOT APPLICABLE APPLICABLE measurement in APPLIC APPLICAB APPLICABLE LE sq.ft.) ABLE

Build up area NOT APPLICABTE NOT NOT NOT NOT NOT APPLICABLE (Measurement in APPLICABLE APPLIC APPLICAB APPLICABLE LE sq.ft.) ABLE

Whether inherited No NOT NOT No NOT NOT APPLICABLE APPLICABIE property (yes or APPLIC APPLICABLE No) ABLE Date of purchase NOT APPLICABLE NOT NOT NOT NOT NOT APPLICABLE in case of self APPLICABLE APPLIC APPLICAB APPLICABLE LE acquired property ABLE

Cost of Land (in NOT APPLICABLE NOT NOT NOT NOT NOT APPLICABLE APPLICABLE APPLICAB case of purchase) APPLIC APPLICABLE LE at the time of ABLE purchase Any investment NOT APPLICABLE NOT NOT NOT NOT NOT APPLICABLE on the property APPIICABLE APPLIC APPLICAB APPLICABLE LE by way of ABLE development construction etc. Approximate NOT APPLICABLE NOT NOT NOT NOT NOT APPLICABLE APPLICABLE current market APPLIC APPLICAB APPLICABLE LE value ABLE

q do" is t i{s' n"t'o$t i',' /s( P's"n,m,r.B

{iv} Residential Buildings (including NOT NOT NOT apartments ) :- Mouza- APPLICABLE NOT APPLICAB APPLICABLE NOT Location(s) APPLICA LE APPLICABL Survey number(s) Kharia, BLE E L.R.Khatian No. 17135

Area (Total 3690 sq.ft. NOT NOT NOT NOT NOT measurement in sq.ft.) APPLICABLE APPLIC APPLICAB APPLICABLE APPLICABL LE E ABLE Build -up area 2100 sq.ft. NOT NOT NOT NOT NOT APPLICABLE (total APPLIC APPLICAB APPLICABLE APPLICABL LE E measurement in ABLE sq.ft.)

Whether inherited No NOT NOT NOT NOT NOT property (yes or ,APPLICABLE APPLIC APPLICAB APPLICABLE APPLICABL LE E No) ABLE

Date of purchase 08.03.1991 NOT NOT NOT NOT NOT 22.05.2002 APPLICABLE APPLICAS APPLICABLE APPLICABL in case of self APPLIC LE E acquired property ABLE

Cost of property Rs.26,000/- NOT NOT NOT NOT NOT Rs.50,800/- APPI.ICABLE APPI.ICAB APPI-ICABI-E APPLICABL {in case of APPLIC LE E purchase) at the ABLE time of purchase Any investment Rs. 10,00,000/- NOT NOT NOT NOT NOT APPLICABLE on the land by APPLICABLE APPLIC APPLICAB APPLICABL LE E way of ABLE development, construction etc. Approximate Rs. 15,00,000/- NOT NOT NOT NOT NOT current market APPLICABLE APPLICA APPLICAB APPLICABLE APPLICABL BLE LE E value

(vl Others (such as NOT APPLICABLE NOT NOT NOT NOT NOT interest in APPLICABLE APPLIC APPLICAB APPLICABLE APPLICABL LE E property) ABLE

(vil Total current Rs.21,00,000/- Rs- NOT NOT NOT NOT 4,00,000/- APPLICAB market value APPLIC APPLICABLE APPLICABL LE E (i)to(v)above ABLE

fl.w d4t:sr ,,Pkm.d;

"sn"Ie*( P' sb,.?r:.k

lr,ooc/i prmr, Stnr,,,r nrfi No..l&2i

details of liabilities/dues to public financial institutions and government :-

(Note : Please give separate details of name of the bank, institution , entity or individual and amount before each item)

sl. Description Self Spouse HUF Dependent- Dependent Depen No. 1 -2 dent-3

(il Loan or dues to HBt Loan NOT A/C No. NOT BanklFinancial APPLICAB NOT NOT NOT 0120010012 APPLICABLE APPLICABLE APPLICABLE APPLIC lnstitution{S} LE 41 ABLE Name of Bank Rs.400000/ or Financial (Jalpaiguri lnstitution Co-operative Amount Small Savings outstanding, Society Ltd.) Nature of loan. Loan or dues to NOT NOT NOT NOT NOT NOT APPLICABLE any other APPLICAB APPLICABLE APPLICABLE APPLIC APPLICABLE ABLE individual/entit LE y other than mentioned above. Name(s),. Amount outstanding, nature of loan NOT NOT NOT NOT NOT Any other APPLICAB APPLIC APPLICABLE APPLICABLE APPLICABLE NOT ABLE liabilities LE APPLICABLE

Grant total of Rs.4,00000/- NOT NOT NOT NOT liabilities APPTICABLE APPLICAB APPLICABLE APPLICABLE NOT APPLIC LE ABLE

(#, fmn"*, *%:$*' T >.)- (A) Has the deponent being in occupation of + F.S. accommodation provided by the Government I) at any time during the last ten years before YE5/NO the date of notification of the current (Please tick the 8\ 5w#fr dealing with \d election? appropriate Govt. (B) lf answer to (A) above is YES, the following alternative) -,Ql.# Waccommodation declaration may be furnished namely :- (i) The address of the Government accommodation: NOT APPLICABLE (ii) There is no dues payable in respect of above Government accommodation towards:- {a) Rent: (b) Electricity charge : (c) Water Charges, and (d) Telephone charges as on (date) [the date should be the last date of the third month prior to the month in which the election is notified or any date thereafter.l Note:- No Dues Certificate from the agencies concerned in respect of rent electricity charges water charges for the above Government accommodation should be submitted.

(i ii) Dues to department NOT APPLICABLE NOT APPLICABLE dealing with the Govt. transport (including aircraft and

Self Spouse HUF Dependent- Dependent Depen t -2 dent-3

(ivl lncome Tax NOT NOT I{OT NOT NOT NOT dues APPUCABTE APPIICABI"E APPLICABTE APPIICABI"E APPLICABLE APPLIC ABLE

(v) GST dues NOT NOT NOT NOT NOT NOT APPLICABLE APPTIC;ABLE APPLICABLE APPLICABLE APPLICABLE APPLIC ABLE (vil Municipal/prop NOT NOT NOT NOT NOT NOT erty Tax dues APPTICABLE APPLIC,ABLE APPLICABLE APPLICABLE APPLICABLE APPLIC ABLE {viil Any other dues NOT NOT NOT NOT NOT NOT APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLIC ABLE (viill Grand Total of NOT NOT NOT NOT NOT NOT allGovt. dues APPLICABLE APPLICABIE APPLICABLE APPLICABIE APPLICABLE APPLIC ABLE (lx) Whether any NOT NOT NOT NOT NOT NOT other liabillties APPLICABLE APPLICABLE APPLICABLE APPLICABI.E APPI.ICABLE APPLIC are in dispute, ABLE if so, mention I the amount 9S involved, and oP the authority ffi D before which it (9) Details of profession or occupation :

(a) Self - Retired High School Teacher. (b) Spouse - House wife.

(9A) Details of source(s) of income: (al Self - Penslon (bl Spouse - NO INCOME. (9B) contracts with appropriate Government and any public company or companies (a) details of contracts entered by the candidate - Nor AppLtcABLE (b) details of contracts entered into by spouse - Nor AppLIcABLE (c) Details of contracts entered into by dependents - Nor AppLIcABLE (d) Detalls of contracts entered lnto by Hlndu Undlvided Famlly or trust in which the candldate or spouse or dependents have interest - NOT AppLICABLE (e) Details of contracts, entered into by Partnership Firms in which candidate or spouse or dependents are partners - NOT APPLICABLE . (f) Details of contracts, entered into by private companies in which candidate or spouse or dependents have share - NOT APPLTCABLE (10) My educational qualification is as under : M.A B.ED. (LLB OF NBUI.

(Give details of highest School/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.) i) Hlgher Secondary pass (1976) Hatdtbari Htgh Schoot ii) B.A - (1979) Ananda Chandra College, Jalpaiguri iii) M.A in political science (1991)- University of North Bengal iv) B.Ed.(1984)A.CTrainingCollege,Jalpaiguri v) M.A in History (1992)- University of North Bengal vi) LL.B Jalpaiguri Law Coltege (NBU)(1988)

kdr>.^-4,ry $ $;&*, On*f,-/ \$eqt e'' PART-B (11) ABSTRACT OF THE DETATLS GTVEN tN (1) TO (10) OF pART_A:

1. Name of the Candidates GOBINDA CHANDRA ROY 2. Full postal address Pathagar Lane Pandapara Road, p.S. Kotwali, p.O. a Dist. Jalpaiguri, Pin- 735101. 3. Number and name of the constituency I CoochBehar (SC) pC,West Bengal and state 4. Name of the Political party which set up ALL INDIA FORWARD BIOC. the candidate (otherwise write

5. Total number of pending Criminal cases TWO 6. Total Number of cases in which convicted NOTAPPLICABLE 7. PAN OF Year for which last Totalincome shown income Tax return filed (a) Candidate ACKPR3121K Financial Year-2017-18 Rs.8,91,c87.00

(b) Spouse NOT APPLICABLE NOT APPLICABLE NOT APPLICABLE

(c)HUF NOT NOT NOT APPLICABLE APPLICABLE APPLICABLE (d) Dependent NOT APPLICABLE NOT APPLICABLE NOT APPLICABLE Detalls of Assets and llabiliUes{lncludlng offshore assets} in Rupees: 8. Self Spouce HUF Dependent-l Dependent- Dependent-3 Description 2

Movable Assets (Total Rs.16,85, Rs.4,59fl) NOT NOT APPLICABTE NOT NOT APPTICABLE ol- A. value) 8oo/- APPtlCABL APPLICABTE E

B. lmmovable Asset Rs.21,00, Rs.4,0000 NOT APPTI- NOT APPTICABLE NOT NOT APPLICABLE oao/- ol- CABLE APPLICABTE

Purchase Price of Rs.4,76,8 Rs.3,0884 NOT APPTI- NOT APPTICABLE NOT NOT APPTICABI.E ol- CAEtE self-acquired ool- APPTICABLE immovable property

il. Development/Constr 10,0000 NOT NOT APPLI- NOT APPLICABLE NOT NOT APPLICABLE uction cost of APPTICAB CABLE APPLICABLE o/- LE immovable property after purchase (if

ilt. Approximate Current market price of (a) Self-acquired asset (Total Rs.21,@,0 Rs.5,0O,O NOT NOT APPLICABLE NOT @l- APPTICABL value) Nl- NOT APPLICABTE E APPIICABtE (b) lnherited Po NOT ..)/ asset NOT NOT APPLICABLE NOT APPLICAB NOT APPTICABL l1 (Totalvalue) NOT APPTICABLE LE APPTICAB E APPLICABLE ,. Q9 tE

^' si +or *t, /lt u.d\ ''

Loans from Bank NOT APPTICABTE Financial lnstitutions and others

Liabilities that are under dispute:

Loans from Bank Financial lnstitutions and others (Total)

ll.Highest educations qualification : M.A B.ED, LL.B of NBU. (Give details of highest school/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.)

i) Higher Secondary Pass (1976) Haldibari High School .i) B.A - (1979) Ananda Chandra College, Jalpaiguri iri) M.A in Political Science (1981)- University of North Bengal iv) B.Ed. (1984) A.C Training College, Jalpaiguri v) M.A in History (1992)- University of North Bengal vi) LL.B Jalpaiguri Law College (NBU) (1988) *:u,tr*J 5w,ft$l.f,

[,r.ts{y: VERIFICATION l, 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 therefrom. I further declare that-

a) There is no case of conviction or pendint case a6ainst me than those mentioned in item 5 and 6 of Part A and part B above; b) l, 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 Cooch Behar this the 19th day of March, ZOtg.

Note: 2. Affidavit should be sworn before on Oath Commissioner or Magistrate of the First Class or before a Notary Public, Note : 3. All column should be filled up and no column to be left blank. tf there is no information to furnish in respect of any item, either "Nil" or "NOT APPLICABLE", as the case may be, should be mentioned. Note : 4. The Affidavit should be 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.

rd$.r;+&d a 6 Gv Solemnlyamrr@ <*ae)I me 0n...... ffi By Sri/Srnt... rg. og .t9 ldentification or sii/i,ri...... :..:::....:..:...... Advocate, Cooch Behar DEBAJYCTI GOI}i,ryP ADVAC,\ coocil BEr_il\f? &H^igl,ffi; eARTHA