J FORM2A (See rule 4) NOMINATION PAPER Election to the House of the People General Elections to Loksabha-2019 1S-Warangal{SC)P.C Date Time ROlnitial SI.No. ,...... ZSl2Jll'} 1,31 p-rn ; ~ j ~Co~ ~ ;,.-.. - STRIKE OFF PART I OR PART II BELOW WHICHEVER IS NOT APPLICABLE PART I (To be used by candidate set up by recognized political party) I nominate as a candidate for Election to the House of the People from the 15-WARANGAL(SC) PARLIAMENTARYCONSTITUENCY. Candidate's Name CHINTHA SAMBAMURTHY[Father's namejlate Chintha Bayanna. His postal address H.No.16-1-295/2RT, Srinilayam Apartment, Near Last Bus Stop, Saidabad Colony, Opp: Charminar Function Hall, Hyderabad His name is entered at Sl.No.69 in Part No.52 of the electoral roll for Hindupur, Nalgonda Town, Telangana State Assembly constituency comprised within Nalgonda Parliamentary Constituency. My Name is ~j~'\)/g~ 7O.kJ::ctI/<?lfdlimd it is entered at Sl.No. I Z 9 in Part No S~ of the electoral roll for the 10~ - t,,_jG\Y~Y\Otl \ 1~eS:.+- Assembly constituency. Date: 25".03.2019 2 , ! PART II (To be used by candidate NOT set up by recognized political party) We hereby nominate as candidate for election to the LOK SABHA, 15- WARANGAL (SC) Constituency. Candidate's Name CHINTHA SAMBAMURTHY[Father's name] late Chintha Bayanna. His postal address H.No.16-1-295/2RT, Srinilayam Apartment, Near Last Bus Stop, Saidabad Colony, Opp: Charminar Function Hall, Hyderabad His name is entered at Sl.No.§.2__inPart No.52 of the electoral roll for Hindupur, Nalgonda Town, Telangana State Assemblyconstituency comprised within Nalgonda Parliamentary Constituency. Particulars of the proposers and their signatures. Sl. Electoral Roll No.of No. Proposer Full Name Signature Date Part No.of S.No. in Electoral that part Roll 1 2 3 4 5 6 Nil Not Not Not applicable Not Not applicable applicable applicable applicable N.B. There should be ten electors of the constituency as proposers 3 , 1 PART III I, CHINTHA SAMBAMURTHY the candidate mentioned in Part I / Part II (which is not applicable) assent to this nomination and hereby declare- (a) I am a citizen of India and have not acquired the citizenship of any foreign State; (b) that I have completed 65 years of age; [STRIKE OUT b (i) OR b (ii) BELOW WHICHEVER IS NOT APPLICABLE} (c) ( i ) that I am set up at this election by the BHARATIYA JANATA PARTY (BJP), which is recognized National Party and that the symbol reserved for the above party be allotted to me. (d) that my name and my father's name have been correctly spelt out above in English (name of the language) (e) That to the best of my knowledge and belief, I am qualified and not also disqualified for being chosen to fill the seat in the Legislative Assembly of this State. *1 further declare that I am a member of the MADIGA-31 which is a SC of the State of Telangana in relation to Nalgonda in that State. 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 simul~aneou.sly,to the House of the People frol more.9it I.antwo Parliamentary Constituencies. ' '~ Date: .03.2019 SIgnature ofCa ' 1 *Score out this paragraph, if not applicable. **Score out the Words not applicable. 4 PART III A (To befilled by the candidate) Whether the Candidate - (i) has been convicted - (a) of any offence(s) under sub-section (1); or (BIG and BOLD LETTERS) : NOT APPLICABLE (b) for contravention of any law specified in sub-section (2), of section 8 of the Representation of the People Act, 1951 (43 of 1951); or Not applicable (ii) has been convicted for any other offence(s) for which he has been sentenced to imprisonment for two years or more. Not applicable If the answer is "Yes" , the candidate shall furnish the following information: (i) CaseiFirst information repOIiNo.lNo Not applicable (ii) Police station (s). Not applicable District(s) Not applicable State(s) Not applicable (iii) Section(s) of the concerned Act(s) and brief description of the offence(s) for which he has been convicted Not applicable (iv) Date(s) of conviction(s) Not applicable (v) Court(s) which convicted the candidate Not applicable (vi) Punishment(s) imposed [indicate period of imprisonment(s) and/or quantum of fine(s) : Not applicable (vii) Date(s) of release from prison Not applicable (viii) Was/were any appeal(s)/revision(s) filed against above conviction(s) Not applicable (ix) Date and particulars of appeal(s)/application(s) for revision filed Not applicable (x) Name of the court(s) before which the appeal(s) /application (s) for revision filed : Not applicable (xi) Whether the said appeal(s) / application (s) for revision haslhave been disposed of or is/are pending Not applicable (xii) If the said appeal(s)/application(s) for revision has/have been disposed Not applicable - 5 " (a) Date(s) of disposal Not applicable (b) Nature of order(s) passed Not applicable (2) Whether the candidate is holding any office of profit under the Government of India or State Government? (No) -If yes, details of the office held. (3) Whether the candidate has been declared insolvent by any court? (No) -If yes, has he been discharged from insolvency: .... (4) Whether the candidate is under allegiance or adherence to any foreign country? ili2l - If yes, give details ..... (5) Whether the candidate has been disqualified under section 8A of the said Act by an order of the President? ili.Q}. If Yes, the period for which disqualified (No) (6) Whether the candidate was dismissed for corruption or for disloyalty while holding office under the Government of India or the Government of any State (No) -If yes, the date of such dismissal. (7) Whether the candidate has any subsisting contract(s) with the Government either in individual capacity or by trust or partnership in which the candidate has a share for supply of nay goods to that Government or for execution or for executing of works undertaken by that Government? (No) - If yes, with which Government and details of subsisting contract(s). (8) Whether the candidate is a managing agent, or manager or secretary of any company or 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? ili2l (9) Whether the candidate has been disqualified by the Commission under section lOA of the said Act (No) - If yes, the date of disqualification .... Not applicable Place: Date: 2:5':03.2019 6 , , ., PART IV (To be filled by the Returning Officer) Serial No. of Nomination paper ~t This Nomination was delivered to me at my office at.. t.~.l..p.:.Y.1.. (Hour) on 2-s.j.a.!.'.1.., (Date)by the 'candidate/pioser. ~~' I Date:.2:5·J·~·l·~q·,. ~ *Score out the world not applicable 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 and decide as follows: Date . Returning Officer ,I I, AFFIDAVIT TO BE FILED BY THE CANDIDATE ALONG WITH NOMINATION PAPER BEFORE THE RETURNING OFFICER FOR ELECTION TO THE LOK SABHA (NAME OF THE HOUSE) FROM 15- WARANGAL (SC) PARLIAMENTARY CONSTITUENCY (NAME OF THE CONSTITUENCY) PART A I,. CHINTHA SAMBAMURTHY [Father'S name] late Chintha Bayanna. His postal address H.No.16-1-295/2RT, Srinilayam Apartment, Near Last Bus Stop, Saidabad Colony, Opp: Charminar Function Hall, Hyderabad (mention full postal address), a candidate at the above election, do hereby solemnly affirm and state on oath as under:- Form 26 (See Rule 4A) Please affix your recent passport size photograph here AFFIDAVITTO BE FILED BYTHE·CANDIDATEALONGWITH NOMINATIONPAPER BEFORE THE RETURNINGOFFICER FOR ELECTIONTO THE LOK SABHA(NAME OF THE HOUSE) FROM 15- WARANGAL(SC)PARLIAMENTARYCONSTITUENCY (NAMEOF THE CONSTITUENCY) PART A I, CHINTHA SAMBAMURTHY[Father's name] late Chintha Bayyanna. His postal address H.No.16-1-295/2RT, Srinilayam Apartment, Near Last Bus Stop. Saidabad Colony, Opp: Charminar Function Hall, Hyderabad (mention full postal address), a candidate at the above election, do hereby solemnly affirm and state on oath "ATTESTED" ~.~~____....., K. SURYAN RAYANA a.Com. B.A. LL.B. ADVOCATE & NOTARY H.Mo: 1-1-336/10, Vivek Nagar. Chikkadpally, Hyderabad-500 0.,'.... Telangana. (1) I am a candidate set up by Bharatiya Janata Party (**nameof the political party) / **amcontesting as an Independent candidate. (**strikeout whichever is not applicable) (2) Myname is enrolled in Hindupur, Nalgonda Town, Telangana State (Nameof the Constituency and the State), at Serial No. 69 in Part No. 52 (3) My contact telephone number(s) is/are 9346821171 and my e-mail id is [email protected] / [email protected] and my social media account(s) (if any) is/are (i) Face Book: Chintha Sambamurthy (ii) What'sup No. 9346821171 (iii) Twitter: Nil 2 { , , , >' (4) Details of Permanent ACCOlnt Number (PAN)and status of filing of Income tax return: Total income The financial shown in Income Tax year Return (in Rupees) Sl. For which the No. Name PAN last Income- tax for the last five return has been Financial Years filed completed (as on 31st March) I 2014-15 \ (i) Nil I 2015-16 (ii) Nil 1 Chintha NIL 2016-17 Sambamurthy (iii) Nil 2017-18 (iv) Nil 2018-19 j (v) Nil 2014-15 (i) 432010 1 i (ii) 388870 2015-16 2 DrB.P. AUWPB7097E 2016-17 I (iii) 412870 Pushpalatha 2017-18 , , (iv) 435300 2018-19 (v) .