ANNEXURE 10 (cHAPTER 5, PARA 5.5.1) FORM 2A' FORM 24 (See rule 4) orr | 6n l:otr leo NOMINATION PAPER Election to the House of the People Z I t t STRIKE OFF PART I OR PART II BELOW WHICHEVER IS 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 02- SRIKAKULAM Parliamentary constituency. Candidate's name VIIAYAKUMARI KINIARAPU Fathers/methe+s/husband's name YERRANNAIDU LATE. His postal address NIMMADA VILLAGE PRIYAGRAHARAM VIA, KOTABOMMALI MANDA L. SRIKAKULAM DISTRICT. HeT name is entered at S.No 704 in Part No 288 of the electoral roll for TEKKALI* (Assembly constituency comprised within) 02-SRIKAKULAM Parliamentary Constituency. My name is RAVEENDRABABU ARAVALA and it is entered at S.No 56 in Part No 83 of the electoral roll for SRIKAKULAM * (Assembly constituency comprised within) 02- SRIKAKULAM Parliamenta ry constituency. Date: 25.03.2019 A.qzi,fu, Signature of Proposer PART II (To be used by candidate NOT set up by recognised political party) we hereby nominate a candidate for election to the House of the people from the- Parliamentary Constituency. we declare that we are electors of the above parliamentary Constituency and our names are entered in the electoral roll for that Parliamentary Constituency as indicated below and we append our signatures below in token of subscribing to this nomination:_ Particulars of the proposers and their signatures S. Name of Elector roll no. of Full Name Signature Date No component Proposer Assembly Part No. S. No. constituency of in that Electoral part Roll 1 2 3 4 5 6 7 1 7 3 1 .-----.--..---.- NOT APPLICABLE 5 6 7 8 9 10 N.B. - There should be ten electors of the constituency as proposers. PART III I, the candidate mentioned in Part I/Part tr{ (Strike out which is not applicable) assent to this nomination and hereby declare that - (a) I am a citizen of India and have not acquired the citizenship of any foreign State or country. (b) I have completed 55 years of age; [STRIKE OUT c(i) or c(ii) BELOW WHICHEVER IS NOT APPLICABLE] (c) (i) that I am set up at this election by the TELUGU DESAM parry, which is a recognised Na+ienaf+arB,/State Party in this State and that the symbol reserved for the above parly be allofted to me. OR (cXll) €rd€+€+f+efu+€n€+ffe:- (d) my name and my Fathel-s/Methe+-s/Husband's name have been correctly spelt out above in ENGLISH (name of the language); (e) to the best of my knowledge and belief, I am qualified and not also disqualified for being chosen to fill the seat in the House of the People. *I r,,.rL^- ,l^-l--^ +L^+ I rL^ ** r---'^ /r-.rl- ,,,] ;-L i. -'- - -^-L^- ^r ^ - ---Staie I also declare that I have not beery 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 from more than two Parliamentary Constituencies. Date:25.03.2019 l(usrP' r-.r'-'-'-* Si gna tusre of Candida te +Score out the words "assembly constituency comprised within" in the case of Jammu and Kashmir, Andaman and Nicobar Islands, Chandigarh, dadra and Nagar haveli, Daman and Diu and Lakshadweep. *Score out this paragraph, iI not applicable. **Score out the words not applicable N.B.-A "recognised political party" means a political Party recognised by the election Commission under the etection Symbols (Reservation and allotment) Order, 1968 in the State concemed. PART IIIA (To be filled by the candidate) Whether the candidate--- (i) Has been convicted ---- (a) of any offence(s) under sub - section (1); or (b) for contravention of any law specilied in sub-section rles/ No (2), of section 8 of the Representation of the people Act, 1951 (43 of 1951); or (ii) Has been convicted for any other offence(s) for which He has been sentenced to imPrisonment for two years or more. If the answer is "Yes", the candidate shall furnish the following information: (0 Case/first information report No./Nos. - NOT APPLICABLE - (ii) Police station(s) - Nor eppllceslr -District(s) - rcr allrrceor-r - State(s) - Nor APPLTcABLE - (iii) Section(s0 of the concemed Act(s) and brief description of the offence(s) for which he has been convicted -Noreprutceslt- (iu) Date(s) of conviction(s) - ror enn-rcaor-e - (") Court(s) which convicted the candidate- r.:or eppuceslu ("i) Punishment(s) imposed [indicate period of imPrisonment(s) and/or quantum of fine(s) - tror *ruc,ror-r - (vii) Date(s) of release from prison - NoTApILICABLE - (viii) Was/were any appeal(s)/ revision(s) filed against above conviction(s) Yes/ No (ix) Date and particulars of appeal(s)/ application(s) for revision filed _ NorAppLrcABLE _ (x) NlT! gf the court(s) before which the appeal(s)/ application(s) for revision filed _ NOT APPLICABLE - (*i) Whether the said appeal(s)/ application(s) for revision has/have been disposed of or is/are pending - Norarrrrceou - (xii) If the said appeal(s)/application(s) for revision has/have been disposed of -- (a) Date(s0 of disposal -rorernucoorr- (b) Nature of order(s) passed , r,ror AIpLTcABLE- (2) \Arhether the candidate is holding any office of profit under the Government of India or Stare Government? rles/ No If Yes, Details of the office held - ruor AppucABLE (3) Whether the candidate has been declared insolvent by any Court? fV*Z i(O If Yes, has he been discharged from insolvency - ror AppLTcABLE - (4) Whethegthe candidate is under allegiance or adherence to any foreign country? (Y*/If,o) -If Yes, give details - Nor arrr-rceorr - (5) Whether the candidate has been d]pqualified under section 8A of the said Act by an order of the President? (Yes/ No) (6) Whether the candidate was dismissed for corruption or for disloyalfy while hold,ing office under the Govemment of lrdia or the Government of any State? (Yes/ ]do1 If Yes, the date of such dismissal - uor erprrcaau- (4 Whether the candidate has any subsisting contract(s) with the Government either in individual capacity ot by trust or partnership in which the candidate has a share for supply of any goods to tl'1gi Governmenl. or for cxecution of works undertaken by that Govemment? (Yes/ No) -If Yes, with which Govemment and details of subsisting contract(s) - r'ror alluceor-e - (8) \A/hether the candidate is a managing agent, or manager or Secretary of any company or Corporation (other$n a cooperative society) in the capital of twenty-five percent share? (\As/ No) -If Yes, with which Govemment and the details there of - Ncrr apelrcaeLr - (9) Whether the candidate h19,been disqualified by the Commission under section 10A of the said Act---- (\Asl No) -If Yes, the date of disquali{ication un arrurceru - Place: SRIKAKULAM. Date: 25.03.2019. Ku*6>.* Signature of Candidate PART IV (To be filled by the Returning Officer) Serial No. of nomination paper ................ This nomination was delivered to me at my office at . (hour) on (date) by the *candidate/ proposer. (name of proposer ................ .) Date Returning Officer PARTV Decision of Returning Officer Accepting or Rejecting the Nomination paper I have examined this nomination paper in accordance with section 36 of the Representation of the People Act 1951 (43 of 1951) and decide as follows:- Date ... Returning Officer (Perforation) PART VI Receipt for Nomination Paper and Notice of Scrutiny (To be handed over to the person presenting the Nomination Paper) Serial No. of nomination paper ............... The nomination paper of a candidate for election from the Parliamentary constituency was delivered to me at my office at (hour) on (date) by the *candidate/ proposer. All nomination papers will be taken up for scrutiny at (hour) on (date) at (Place). Date Returning Officer "Score out the word not applicable. I ) J J tr I I L] g U , N l 1 001 00 1 001 0 6 a o , TI 1 lrl I D A eeo&Fdf, srr*rytvr ANDHRA PRADEsH CG 936540 g5 ,,. i iah ii:.io S r'/o .Daregpg4gRs.ssl- i rr -r<d i.r..,.. r: r, i T'o SoJd lnirryerxsud.-lGn:orup dlo Yqnnayry,oid.1 Lc< Slir-r4r0ecm Fo,' !arhcrl_---tl1g_' Form 26 AL4.',/ALASA/ I (See rute 4A) t I ./, I I' // t AFFIDAVIT TO BE FILED BY THE CANDIDATE ALONGWITH NOMINATION PAPER BEFORE I THE RETURNING OFFICER FOR ELECTION TO LOK SABHA (House of the people) (NAME OF THE HOUSE) FROM 02, SRIKAKULAM PARLIAMENTARY CONSTITUENCY (NAME OF THE CONSTITUENCY) PART A I VIIAYAKUMARI KINIARAPU +'16oft/dau6ht€r/wif! of YERRANNAIDU LATE. Aged !! years, resident of NIMMADA VILLAGE, PRIYAGRAHARAM VIA, KOTABOMMALI MANDAL, SRIKAKULAM DISTRICT (mention full postal address), a candidate at the above election, do hereby solemnly affirm and state on oath as under:- I B il1 KW't* N.S. o, IT'E8'ED No R/617/2009 13/2018 Ranni?d Valid u 1-0 l-2024 I SRIKA LAM TOVVN I I s **am (1) I am a candidate set up by TELUGU DESAM PARTY (*'name of the political party) / @. (**strike out whichever is not aPPlicable) (2) My name is errolled in 03 - Tekkali Assembly Constituency in Andhra Pradesh (Name of the Constituency and the state), at Serial No. 204 in Part No.288 - Nimmada (3) My contact Telephone Number(s\ is/ are949346839 and my e-mail id (if any) is - NIL - and my social media account(s)( if any) is/are (D - NrL- (ii) -NrL- (iii) - NIL- (4) Details of Permanent Account Number(PAN) and status of filing of Income tax return: Sl.No Names PAN The financial Year Tota.l income shown in lncome Tax for which the last Return (in Rupees) for the last five Income-tax return Financial Years completed (as on 31't has been filed March) 1 Self APTPK6179-A 20"t3 - 2014 (D 12,60,30't / - 2011- 2015 (ii 1-t,80,542 / - 2075 - 20"t6 (iii ) 75,26,057 /- '15,74,394/ - 2016 -2017 | (ir ) 2017 - 2018 (rl '15,77 ,555 / - 2 Spouse NlL NIL (') NIL NIL (ii) NIL NIL (iii) NtL NIL (iu) NIL NIL (v) NIL 3 HUF (lf Candidate is NOT NOT (') NOT APPLICABLE Karta/Coparcener APPLICABLE APPLICABLE (iD NOT APPLICABLE (iii) NOT APPLICABLE (iv) NOT APPLICABLE (") NOT APPLICABLE .1 Dependent 1 AI APR9645-P 201,3 - 2014 (i) 1.-1 ,78,695 / - -rs,26,705/ 2074 - 2075 (ii) - 2015 - 2016 (iiD 13,63,765/- 20^t6 - 2017 (iv) 't6,37,568/ - 2077 - 2078 (v) 15,-t5,^142/ - 5 Dependent 2 NOT NOT (i) NOT APPLICABLE 4 N.S.