.-t'"u,"2\11.1:"'"'*" NOiUINATION PAPER Electk,l to th. Hauvafthe People 7\ }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$e/tribe .. ... in rc!arion \hi.h is a scheduled ol ihe State .r ......r<.gel:....Gs.-*-i.+]..:. R* @mumd aM Diu -"",;;il;;;;";Ni"J", kr.nds. cilaidilarh Dadm and Naarr ttav'li' Darnan lscoreout dris p.ragmph. ilnor dtpliclbl'' .+s..rco nre \rordsn.r applicablc prii) rccognh.d br_ the Eleclion N B.-A Lcco!' F.Ll poli' nrr\' mcin\ J polnirrl 'r Ordct 1963 nl the stdc cominbsu, r ri* rlt Els' un SJmbols lRrser onJnd Allouncno , T RT IIIA I obefiledb) '.3 dd, el (l) she(herthe candidaLe - (i) ha been.otrlided - G) otaryolienc(s) urd sub secrlon (l)ior : pc! .r 'bi lo' !o'.'..e",or of 1\ I \. leJ'i b-,e!rio, ilL c' . 'i,. q " r R.p e. fl E .. , r ' , . o .opl . A. ' ' o.r\o (ii)has becn conricrcd 6r anr orh.roffcncc(t for which hc has bccn semenced ro inprisonmcnt lbr t$! ) 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.