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`Yi-
^. NATION PAPER
f2 C/fr
Before the Returning Officer
For election to 4)!±!{(^L^E,(,it,R-11V^^sSt (name of the House)
From . .............^^
constituency
(Name of the Constituency)
.......^^?'.^9....... ^ .-.'^!....,1.__.... ...
... kk W - 4 n . ..... o ...
Son/dai}ght erl^ ife
Q. ......}^ et '!Y... aged .. _.
re>d
> ent of ..V^J1 . t..(^b:...l^ I^.U..C^i ......
Candidate at the above election ,
. L) Ye
do hereby solemnly affirm and state on oath as under:-
(Strike out whichever not applicable)
1. The following case (
s) is/'e pending against me in which cognizance has be
taken by the court:0) Section of the Act and description
of the offence for which cognizance:
taken : 1 LS 14
I. 19 $ I I \A
9S 133 32 1 -3 7- 5- SO 332
,
(ii) The Court which has taken cognizance
iii) Case No,
: 0-'-T "-
^)AkGyIA^h7j}^
c
Date of order of the court taking cognizance : J . D , p
Details of appeal ( s) / application ( s) for revision
above order taking cognizance
1` bpo
L4
. etc. if any, filed agai sr
A- ,daTI lb
4,
L1
1s^^
erc'^C
(immovable, movable, bank
details of the assets
below
the
give
herein
2) That 1
d dents and myself
balance, etc) of spouse, my epe n
(A) DETAILS OF MOVABLE ASSETS
(Assets in joint name indicating the extent of joint ownership will also have to be
Spouse ( s) Dependent-1
Name ( s) Name
tam
I SI^1T SIt A , I0 "T-TTJ
^^V I
__Oe?o^-'
I
Rsr
(t)
(v)
Other financial
9 L- ' r
instruments , NS S ,
postal Savings , LIC ^(^J ^^;QSl^kh II
Policies, etc.
Motor Vehicles
(Details of make,
etc.)
lIl-
1 I-1 I t
Deposits in Banks
Financial
Institutions
And Non- Banking
Financial
Companies
Bonds. Debentures I
and Shares in
ompanies
Lo RT^^()
^^I 50)A'7
19- 1-591
t
( give CAo -
S
t
MI L
^1 I L I t.1 11_ Iy
Net - '50 1"7 1i (nd
PSJewellery
PJ iZS $S
(co l
I details of weight !6l- QS. a IQ
and value) 045M^1- soon(
I_)) L_
(vii) other assets, such1 „ft
as values of claims/ 1 k5•}n^"^
N"-
interests
it, St''ck
the latest market value
Debentures
as
per
case of P. 0111
of Bonds / Shares /
Note: Value
Exchange in respect of listed companies and as per books in the
listed companies should be given. A fit ^^
.^
y c_ ^_. i s r m "aa a person substantiall}r de ^ J
,.^ ^ay,to nn the 1i1('NT
di
B. DETAILS OF IMMOVABLE ASSETS
ill al
[Note : Properties in joint ownership indicating the extent of joint ownership w
have to he indicated]
Dependent-I I Dpendru-2 I i9ependeu,
Self ' Spouse(s)
Description
ti atne(s)
41I
r,
'
9i-TA DPI
(i) Agricultural Land- Locations(s)
- Survey number(s)
- Extent (Tota l
I
measurement)
Current market value
Name
Nani etc Nan",
Se^N
Sort ^ccaj
iii
pJIvu
tlnhLR^
ytll-S9A
-te ar
t n' "1' '
o
H•F.
'
W
3oE
l
.tp
N tt-
A-P.6^* 19dk. Rsslakh
6^bo loLskh a}itlrd
] (ii) Non-Agricultural Land- "l'pIs
Locations (s)
7J I L
Survey number(s) t l
ps.7t^l
- Extent (Total
N
measurement)
- Current market value
I
'
^ Buildings (commercial o ^
and residential) v,
Jl-
- Locations(s)
I
7cQk^
ILI)
- Survey - door
numbers(s)
- Extent (Total
measurement)
- Current market value
(iii) Houses Apartments,
etc- Locations(s)
- Survey door
numbers(s)
- Extent (Total
measurement)
- Current market value
(iv) Others (Such as interest
in property)
il
X11 l-- til ^ ^
N1L
I give herein below the details of my liabilities ' over due to public financial
institutions and government dues:-
[Note : Please give separate details for each item)
Amount
outstandinL as
or, . ............
i Name & address of
1 Bank/FlnancialInstitutions(s
Departments(s)
(i) Loans from Banks
13^oAt^^s4^
T At4 \c of . h I A-
(ii) Loans from financial institutions
I
^)I( -- (iii) Government dues:-
Ps .SsoOO`-
QS as-n OO
giL iu Vt4a,
^'I1y.
oYt
(a) dues to departments dealing
with government
accommodation
Vl^(b) dues to departments dealing with
supply of water
(c) dues to departments dealing with I
supply of electricity
t t-
N1L
(d) dues to departments dealing with
telephones
(e) dues to departments dealing with
government transport (including
aircrafts and helicopters)
(f) other dues, if any
" 1\
'
A moun t
• - Name N address of
Description
Banlo'Financial Institutions(s)i outstanding as
Depat?menc^ts) L on .(i) Income Tax Including surcharge
[Also indicate the assessments year
u p to which income Tax Return
AP-zpy
-9
144
filed. Give also permanent Account 7gI 9-10
Number (PAN)]
Wealth Tax [Also indicate the
assessment year up to which wealth
Tax return filed.]
t--
o
Sales tax [Only in case o
proprietary business]
(iv) Property Tax
(4) My educational qualifications are as under :- (>q , A . eH'X^,.
[GIVE DETAILS OF SCHOOL AND UN[VERSITY EDUCATION]
[Name of School ! University and the year in which the course was completed
hould also be given .] fI, g
Y9 bpj {xe d h1 t.2T,kN , Ph.D,!P
L• N xy, c-1. Qtg4Z hA11tny^
` vat b`-j,^} til^tbl
DEPONENT
VERIFICATION
1, the deponent &v-- aarned , do hereby verify and declare that the content , of thi<
affidavit are truerdnd correct to the best of my knowledge and belief; no part of it is
false and nothing material has been concealed there from.
^.
Verified at . .. ... ... this the........ ^.. d:ty 0 ` ..h..f
:.:
......[
!^P tl4l t^°"nen
:--,
NT" it sdM i
afit 13fk
41&R
t
Af
ffft
Date fixed for notifyln
the requisite number c,
stamps and folios.
Mr F
t
Date on which the copy
was ready for delivery.
Date of making over the
copy to the applicant.
folios.
P91g110 I ¶3191(0
L
-.^^
,6 1/
.
* at
m fNam)d *t
MfRN
Date of application for
the copy.
qmf^lili
VW Tftff T(4 ED 4ol^
aft
Date fixed for notifying
the requisite number of
stamps and folios.
Date of delivery of the
requisite stamps and
folios.
Date on which the copy
was ready for delivery.
?J^ 2✓
7(
7
rl A
Ri
Date of making over the
copy to the applicant.
7
' ^r
twilliigt I•i44 uI
>I 1, ^ F
41
a!kj q I ^ o
*4.61 trill
Slid i
.. ... ... ...
Rio kv.i '$ .4
1 y.S
q'd q ,, Zv ii '. -,
a.l PI ) a c
-3o
"I'MIR *f a4i^1 ln,,oi
FORM A
COMMUNICATION WITH REGARD TO AUTHORISED PERSONS TO
INTIMATE NAMES OF CANDIDATES SET UP BY RECOGNISED
NATIONAL OR STATE POLITICAL PARTY OR REGISTERED
UN-RECOGNISED POLITICAL PARTY.
[See paragraph 13(c), (d) and (e) of the Election Symbols
(Reservation and Allotment) Order, 1968]
To,
1. The Chief Electoral Officer,
............?t ..........................................................(State/Union Territory)
2. The Returning Officer for the
S..
..................
ea$1 ........................................... Constituency.
Subject: General/$y( Elections to
..................
from ................. it.^A15 ............................................ (State/Uior-territory)Allotment of Symbols-Authorisation of persons to intimate names of
candidates.
Sir,
In pursuance of paragraph 13(c), (d) and (e) of the Election Symbols (Reservation
and Allotment) Order, 1968, I hereby communicate that the following person(s) has/have
been authorised by the Bharatiya Janata Party, which is National Party in the State
of ........................W, iA21 .................................... to intimate the names of the candidates
proposed to be set up by the party at the election cited above.
Name of person authorised
to send notice
1
1
Name of office held
in the Party
2
District(s)/area (s) constituency/
constituencies in respect of
which he has been authorised
3
2. The specimen signatures
of the.above mentioned person(s) so authorised are given
below:1. S p ecimen si gnatures of Shri .........^..,^.... .
(i) ............ :. :.. r,:^ ....... (ii) ...
l `J C''r .....................
(iii) ...........
2. Specimen signatures of Shri .................................................................................
(i) ......................................................... (ii) ..........................................................
(iii) .......................................................
3. Specimen signatures of Shri .................................................................................
(i) ......................................................... (ii) ..........................................................
( iii) .......................................................
Yours faithfully,
Place N e.w 'h ,-
IT IN GADKARI)
President
q • p t) t)
Date ................`
^.:................ Bharatiya Janata Party
/A J
AN
o-,ionj u.1*
N.B.
:
1. This must be delivered to the Returning Officer and the Chief Electoral Officer not
later than 3 p.m. on the last date for making nominations.
2. Form must be signed in ink by the office bearer(s) mentioned above. No facsimile
V
FORM B
NOTICE AS TO NAME OF CANDIDATE SET UP BY
THE POLITICAL PARTY
[See paragraphs 13(b), (c) and (e) and 13A of the Election Symbols
(Reservation and Allotment) Order 1968]
To
The Returning Officer for the
Q 6.'... 1 ..........................................Constituency.
Subject: General/Bye-Elections to m!
.....................................
^
...........
from ..
..-.........-1
. .......................................... (Name of the Constituency)
in ...............1: 1. .1. ......................................... ( State/Un'
1Da--T€rritory)--setting
up of candidate.
Sir,
In pursuance of paragraphs 13(b), (c) and (e) and 13A of the Election Symbols (Reservation
and Allotment) Order, 1968, I hereby give notice on behalf of Bharatiya Janata Party-(i) that the person whose particulars are furnished in columns (2) to (4) below is the
approved candidate of the party above named, and
(ii) the person whose particulars are mentioned in columns (5) to (7) below is the
substitute candidate of the party, who will step-in on the approved candidate's
nomination being rejected on scrutiny or on his withdrawing from the contest, if the
substitute candidate is still a contesting candidate, at the ensuing general/bye election
from this constituency :
Name of the
constituency
Name of
the
approved
candidate
Father's/
Mother's/
Husband ' s
name of
approved
candidate
Postal
address of
approved
candidate
Name of the
substitute candidate
who will step-in on
the approved
candidate's
nomination being
rejected on scrutiny
or on his
withdrawing from
Father's/
Mother's
Husband'
s name of
substitute
candidate
P os t a l
addre ss o f
s u b s ti tute
candidate
V
*2. The notice
in Form 'B '
given earlier in
Sushri ................ favour of Shri/SmtJ
.......................................
candidate Shri / Smt./Sushri
Party'
"" """"" as party's appro% ed
s substitute candidate is hereby rescinded.
13. It is certified that each of the candidates whose name is mentioned above is a member
of this political party and his name is duly borne on the rolls of members
of this party.
Yours faithfully,
Place ....`.f
(Name of the
..............
Authnr;
arty)
Date ..^...o: o..
^Y p I D
.................
N.B..
I • This must be delivered to the Returning Officer not later than 3 p.m. on the last date
for making nominations.
2. Form must be signed in
ink by the office bearer( s) mentioned
signature or signature by means of
above. No facsimile
rubber stamp
accepted.
, etc., of any office bearer shall be
3. No form t ransmutted by fax shall
be accepted.
s
s'
Vw
^^yy
EV,URE
_ Y 11)
Ar.N
PARA
CHA^TE12 V[1,
EN SIGNATURE.Of CA^p1DATES
CIM ACiF.N"rS NO &
FORMAT FOR SFE T10N
General
AND THEIR ELEC
election .
I B mial D -.
Name of'' kssemb y
Sabha Constitue ncy
.
.
.
L.ok °_ .. ... .... .. ... ... ent are ^_IV OYr bt't0 A'v .O}' l le
licabe oiilt mcili of
candidates and 0. eir t.l 11U1n Af
(Delete whatever is not app
f contesturg the Presiding; Off.ce, n, the lett^.; of apF
St matun o
The specunen
b ,natures by
of their s,g - 5t, ^,nreu
purl)
ose
of
venfication
S
is at
the tune
of Poll'.
rv Namr, of hisl^
rn
it
,
Wa
ccuon`
polling Age
Gl
5 pecrmen
_
Name of the Contesting
Sl.
No.
Cand,date
AN \
nilu
twF,:
io t'1 N2N1NCr Ole lrit'i;E'•
place:.......
............
Date:.........
..........
tar" TriTfuEmt,
f'Errar
?Tall f ff
iw
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n r ^
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BTW ............ .s^....".........
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?aut r3 ?i r rr..'....... 7 9: .? .!9.1 :4.........
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