~"

,\. -.... . ... .__--,..-....

"

FOR'\'f 21:(S~c rule f)

NOi\l[]\!ATION PAPERElection to the Legislative Council of _rr.~ (State'

constituency (,JBI:(.~.cP;., .

PARTl

We hereby nominate as a candidate [Of election to the Legislative Councilof /f~ _..................(State) from the constituency.C3nd,'s name ·Fb·Ita()IZJ.l?~ r; .krn~ M~ ..(~athcr's/Mothcr's/Husband's nam, e). .. ·r~,'" ....~~~V'~.~~~ ..HIS Postal address ...fkIO'.~..~Oy d;(l~.V:i>.~;~6<YJ...... ·.... ···.. ··...... · : His name is cnt~cd at Sf. No·..ltt.q ...... in Part No...... J,g';f-of the electoral roll for ~.~~ As·se!llblyConstituellcy.

We declare tbat we are CleCtOf315al~ our name entered ill the electoral rollfor.. , .. , . , hJ.~ ..' ~ , (Council) constituency as indicated below

"There should be ten per cent. of the electors of the constituency or ten such electors whicheveris less, as proposers. , 43> ~'% 1akgo.-w, 1aya.hJ'M.P.J

~) 11,.. I+',,- fl.Pvfu,

1

._.--. -

r, the :lbnVe-mcnlioned ca1lr.iidarc, assent ro this a n miildlio,~ 2,~" r,c::-e::ydcdarc:--

(a) I am a cirizenoflndia und have not acq'lif(;d the Cili,>eIl~h:p ofany foreign State;Ih) Lhave C01Jlpl~tcfl L\ () 1\/l''' rs 0""- " _'\- ,.~ . c .-- ,~ <11 .• w!;t:., .

(c) r am set up at this election by till.'; Q2r.)~~.ed).~ ~ Pfirty;

(d) my nama and my (fali,cr·sim')\l.er·Sihr,band·S namel has ~eell correctly ,pelt OUI

above in .. .. ..~ 1---m r (name C! the laognage); and

Cc) to .!he best, of my !<.nC\\-ied~~and ~Clief'li am qt~atific;d 2'..nd not a~so ~j~qUalified f~rb~lng cnosen to fill the seat' in the' LeglSlanve. COUllCI!

Of.····················(f.~ (state) from

..'"...... .. hJ ~ ".- ..Counci] constituency .

r I

t·

. I also declare that I have not been 2!lJ shall not be, nominated as it c:indidate at theI . . - ....

present ~iennial ekction/'oye-elec[ions being held ~irnultaneously, to !be, E..egisJative Council of

.....f~ .......(S"".) from more 'ht hvo CouncilcC''''"turncies in the State,

Datc··l.Y.:.,5::-~J9 / f.~~~ ~~Sign{lture of-the Candidate _

'Seo,. Out Ih.words nul applicable ~~ ~ __ .

PART 11(To be filled by the candidaraj

(1) \\n.cth~r the c.andidate.-0) cas been conviciefr-.- I. (a) of an~: ()lTcn<:e,(s) under sub-section (J)~ or '. . ~ .

(b) f~r contr.3.'· <H10I1?f an~ l;:;w ~peclfied In su_b-s~~tlOn {.2), o.t s~chon 801 the .Rep~¢:;'~~I.alnnol1be Pecpl~Act, !9) 1 (4.) of 1951), o.

(ii) has be;_n·cO.lJ':iC~~~fOT.any Other ..offence(s) tor/whiCh be hasbeel~~en{''nced:fl, lmpns~~r:mentlor twoye~rsOf more.

(i}Cct.~·"!:Fir.'~t7';:-&.. .2,:'''''' ::t:;-{..;i N\).i~OS 1 .,("'l'~[D·~'f;''''-<;~!t.r.~;,l>- _ istrict(s) , ..t V '-41 _l' ..... a..o .•{.~~'\ t., .'... ~__,.~"I.~.",,,,,,,,_,,.,,,.,,,.,,:,

2

v

• f~ ..~,.,

.>

(iii) scctiorus) of the concerned Act(s) and brief description or the offence(s) for which hehas been convicted .

(iv) date(s) of conviction(s) .(v) Court(s) which convicted the candidate .(vi) Punishment(s) imposed [indicate period of imprisonment/s) and/or quantarn of

fine(s)] .(vii) Date(s) of release from prison......................................................... V(viii) Was/were any appeal(s)/revision(s) filed against above conviction(s) Yes/No(ix) Date and particulars of appealfsj/applicationfs) for revision filed .(x) Name of the court(s) before which the appeal(s)/application(s) for revision

filed ..(xi) Whether the said appeal(s)/application(s) for revision has/have been disposed of or is/are

pending .(xii) If the said appeal(s)/appiication(s) for revision has/have been disposed of-

(a) Date(s) of disposal.......................... -(b) Nature of order(s) passed .

(2) Whether the candidate is holding an~ce of profit under the Government of India or State

Government? (YeslNo)

-lf Yes, details of the office_held................................... . _ ~

(3) Whether the candidate has been declared insolvent by any Court? (Yes/No)

. -If Yes, has he been discharged from insolvency ..

(4) W~r the cand·idate is under allegiance or adherence to any foreign country? ..

(Yes/No)

-lfYes, give details -

(5) Whether the candidate has been disqualified under section 8A of the said Act by an order of\.,./""

the President? (Yes/No)

-If Yes, the period for which disqualified .

(6) Whether the candidate was dismissed for corruption or for disloyalty while ~ office

under the Govemment of India or the Government of any State? (Yes/No)

.-lfYes, 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 any

3

goods to that GOVCl~ or for execlJtion of works undertaken by that

Government? (YcsINo) I

-If Yes, with which Government and details Ofsu~sisting contractis) .

(8) Whether the candidate is a managing agent, or manager or Secretary of any company or

Corporation (other than a cooperative society) in the faPital 0fwhich the Central! Government

or State Government has not less than twenty-five percent share? (Yes/nY

-If Yes, with which Government and the details thcreof.. .

(9? Whether the candid\at~ been disqualified by the Commission under section lOA of thesaidAcL ....... (Yes/NO)- If yes, the date of disqualification I .

Place:Date: \ ~ ~o5-'}O \,

---------------------+--------------------------------.. PARTUJ

. (To be filled by the Rer~ning Officer)Serial No. of Nomination Paper. l.-:-:7- ..,«, I

Th·· .. d u d I ffi <2<S) ~ rtrM (b )IS nornmanon was e Ive~ me at RY 0 _ ee at " v..:.+ our on

.. .1'-< :5~)~~(date) by the candidate/proposer .r~.~~ ..~Datc.Lf:t »: L"l" I

,~~~ignature of the candidate

. . PARTlVI

Deci~i~no~.~e~urn~n~Officer accepting or re.iectin1 the Nomination PaperI

have' examined this nomination paper \n accordance with section 36 of the

Representation of the ~eoPle Act, 1951 and decide as iOUOWS:-• .f •• _ .

Datc .Returning Officer

4 I

I

I.I

I

I

I

, .

PARTV

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 to the Legislative Council of (State) fromthe.: Graduates'/(Teachers'/LocaJ Authorities')constituency was delivered to me at my office - at (hour)on (date) by the candidate/proposer _ (Name).,Jl nomination papers will be taken up for scrutiny at (hour) on (date)

'.' at (Place).

Date . \-Returning OfficerNote.v-wherever alternative is provided score out the word(s) not applicable.

5

Original/Duplicate (Original to be kept with nomination paper and

1) ; ...~

duplicate to be handed over to candidate)Check list of documents in con cti~n with tili!lg of nomination

Name of constituency ~q,~iJ9J I t ~ .Name of the candidate 'P<?...~D!At.:..~rr1f:lJ:~~.~\;;~ .O d ti ffil' .. p.. O~,.1.,o1~ate an time 0 J JOgnorrunatron paper T7 l J .

Sl. No. of nomination paper............ . .... ... .....

I SI. no. I Documents ~hether filed (Write Yes/No) Ii I! I If there is any !

I

defect/shortcoming III the I

II documents, the same should_

I be specified}I I

II. Affidavit in Form 26- I t

!

I(a) Whether all columns tilled up. I ye,,> I

II(b) If not, which are blank column(s) (PleaseII

specify) tIi

the affidavit is sworn eforc an!

I (c) Whether iI

IOath Commissioner or Magistrat of Firs: NotlAOd pub~;c I,

I Class or before a Notary Public. I ______ iI

2. Certified extract of electoral roll (when' calnd!date is ~ ian elector ofa different constituency) I' '. I NO I

I,~ Form A and B (applicable in the case-e+dandidates- ----- - I.).

I. I ND I

set up by political parties) . . .1' I4. Copy of caste certificates (if the candidate lciaims to

belong to SC/ST) I N{)'-1" j5. Security deposit (whether made) j Y!--5 I

I· J6. Oath and affirmation (whether taken)\ Ye.....>

L--. '" Contd_

-

,',

..The following documents which have not been filed sh()u_t~Jbe filed as indicHteu below: -

(a) ~ should be filed latest by

(b) Above mentioned columns in the Affidavit in Form 26 have been left blank. You must -

submit a revised Affidavit with columns duly filled up before the commencement of

scrutiny of nominations. failing which the nomination paper will be liable to be rejected.

(c) ~ should be filed latest by _

Received

(Signature of candidate) (Signature of ROj ARO)

Date& time:Place:

N.B.1. The Affidavit in Form 26 and Form A & B have to be filed latest by 3.00 P.M. on the last

date of tiling nominations .

. 2. If columns have been left blank 111 the affidavit in Form 26, this should be specified

against item 1, and candidate should be asked to submit an affidavit complete in all

respect, latest by the time fixed for commencement of scrutiny of nominations. Failure to

submit revised affidavit complete in all respects, even after reminder by RO will be a

ground for rejection of the nomination paper.-

·3. Oatlrhas to be takerrafter filing nomination paper and before the Elatefixed for.scrutiny.

4. Certified extract of electoral roll can be filed up to the time of scrutiny.

---------

@ SI.No.2741, Dt.13-OS-2019, Rs.l00/-Pakanati Ramakrishna Reddy S/o Raghava Reddy1R/o Chinnavangara,Self

Ucenced Stampl..No: 21~112015, RL.NoC/o. EUla\'sn! Xe;o.x, Tn,

FORM 26(See rule 4A)

AFFIDAVIT TO BE FILED BYTHE CANDIDATE ALONGWITH NOMINATION Pfi"j-" , / 1. 1 r: 0 I~ tWI ber 0+ Ie q IS D.1J"'e '-0U Y')UBEFORETHE RETURNING OF~ICERFOR ELECTIONTO.................... 0

~ (NAME OFTHE HOUSE) FROM W.Q,.~0fj 9:M CONSTITUENCY(NAME OF THE CONSTITUENCY)

i I P'q,_ko..n.~i.;.:.~"!.(',..)::':.~s.~~"'R~~~:~Of.(QkP.,~"t.~:.R~bC!,Y.AKJ..J~....iAged.~~.a ears, resident of ....-li~.~.O'.,I...l::-......P..!.J~.!1~.v..~!YJ(lYA..\tf.Jl~(t.~i...~ ....~.y.~X~~'yQ" (\1\.J..t\.t'l. . ' (mention full postal address),

a candidate at the above election, do hereby~mnlY affirm ~~Jstate on oath as under:-

I(1) I am a candidate set up, by---.dnd~f------~-~-~~_~_.a._tf(**lIIamO-Ofithe pGlitiral party) /, **am contesting as an Independent cafldid.ate.l~*strike out whichever is not applicable).~ (2) My name is enrolled in r~.I.aJ~~"d!~~ (Name of the Constituency and the state)," at Serial No....J!t.1--.in Part No ....l.&."f..... ~7-I(3) My contact telephone number(s) is/are ~1~..~.?::t Y. and my e-mail id (if any)

". 'L\ t'\:U lSo5'U>'loe~mtJ{.U:rn? .. ..• I~ !.t} J and my social media account(s) (If any) Is/are

. (I) .

~ (ii) , ..

~ ( J

SI. No. Names PAN The financial year Total income shown infor which the last Income-tax return (inIncome-tax return Rupees) for the last fivehas been filed Financial Years (as on the

31st March)

--I. Self (i)

N\.L (ii)f---. (iii)No y>o..""t')

"HL.- ------

~\\o-tteJ(iv)

,----_._-

>------ 1---(v)

2. Spouse (i)(ii)

~lL(iii)

NtL (iv)

(v)

3. HUF' (If the (i)Candidate is (ii)Karta orCoparcener) NIL NtL (iii)

(iv)

(v)._.- - -_----- .-.----~-..----I-- ._-_._-----·t. Dependent-I (i)

(ii)N~\t. NtL- (iii)

(iv)(v)

S. Dcpendent-2 (i)

(ii)

Nl/L Nlk (iii)

(iv)

(v)

6. Dependent-3 (i)

N \L- 101v'(ii)

(iii)

(iv)(v)

Note: It is mandatory for PAN holder to mention PAN and in case of no PAN, it should

,~ • I I

, ,

be clearly stated "No PAN allotted".

(5) Pending criminal cases

(i) I declare that there is no pending criminal c~se against me. (Tick this alternative if

there is no criminal case pending against the Candidate and write NOT APPLICABLE

against alternative (ii) below)

OR

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

(If there are pending criminal cases against the candidate, then tick this alternative and

score off alternative (i) above, and give details of all pending cases in the Table below)

Table

(a) FIR No. with name

(b)

and

Police

address of

Station NOf ~r""Co.b 1('concerned

Case No. with Name

of the Court

(c)

(d)

(e)

Section(s)

concerned

Acts/Codes involved

(give no. of the

Section, e.g.

Section of IPC,

etc.),

Brief description

offence

Whether charges

have been framed

(mention YES or

NO)

of

· - -, .f r

(t) If answer against (e)

above is YES, then

give the date on

which charges were 1\)61oypl:tlEframed

I(g) Whether any

Appeal/Application

for revision has been

filed against thet\)Ol cfp'i~~

proceedingsI(Mention YES or

NO)

(6) Cases of conviction

(i) I declare that I have not been convictedlfor any criminal offence. (Tick this

alternative, if the candidate has not been con icted and write NOT APPLICABLEI

I

against alternative (ii) below)

(ii) I have been convicted for the offences::tioled below:

(If the candidate has been convic~ed~then tick tJiS alternative and score off alternative

(i) above, and give details in the Table below)

(a)

Table

(c) Sections ofActs/Codes involved(give no. of theSection, e.g.Section of IPC,etc.).

Case No.

(b) Name of the Court

(d) Brief description ofoffence for which No! c,rp'~eobl~convicted

(e) Dates of orders of NolcfP\~eo.hle'conviction(f) Punishment imposed (\Jo''1r )~~1~ ,.._

(g) Whether any Appealhas been filedagainst conviction 1\)0lOPP )1"cJJ )eorder (Mention YESor No)

(h) If answer to (g)above is YES, give

N 01 CXf Pt'cJJlrdetails and presentstatus of appeal

(6A) I have given full and up-to-date information to my political party about all pendingcriminal cases against me and about all cases of conviction as given in paragraphs (5) and(6).[ candidates to whom this Item is not applicable should clearly write NOTAPPLICABLE IN VIEW OF ENTRIES IN 5(i) and 6(i), above]

Note:1. Details should be entered clearlyand legibly in BOLD letters.2. Details to be given separately for each case under different columns against each

item.3. Details should be given in reverse chronological order, 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 (C) No. 536 of 2011.

(7) That I give herein below the details of the assets (movable and immovable 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 begiven.

Note: 2. In case of deposit/Investment, the details including Serial Number, Amount, date ofdeposit, the scheme, Name of Bank/Institution and Branch are to be given.

Note: 3.Value of Bonds/Share Debentures as per the current market value in Stock Exchangein respect of listed companies and as per books in case of non-listed companiesshould be given.

Note: 4. 'Dependent' means parents, sorus), daughteris) of the candidate or spouse and anyother 'person related to the candidate whether by blood or marriage, who have noseparate means of income and who ~re dependent on the candidate for theirlivelihood. \

Note: 5. Details including amount is to be given ~eparately in respect of each investment.

Note: 6. Details should include the interest in J\r ownership of offshore assets.

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

Ior institution abroad, 'and details of all assets and liabilities in foreigncountries. \

S.No. Description Self SP"'''l HUF Dependent-l Dependent-2 Dependent-3

I(i) Cash in hand

tJOI~ f\HJ NtL- '50/f%fJ1- Nl'L---- (\}1LI

(ii) Details of deposit in Bankaccounts (FDRs, TermDeposits and all other ~lLtypes of deposits ~\\_ ~'Lincluding saving I\)\L ~n ~\'\....

accounts), Deposits withFinancial Institutions,Non-Banking FinancialCompanies andCooperative societies andthe amount in each sllchdeposit

\

(iii) Details of investment inBonds,

t-j\l N\L "HLDebentures/Shares and ~\l ~\L. ~\Lunits III

companies/Mutual Fundsand others and theamount.

\

, .,

(iv) Details of investment inNSS, Postal Saving,Insurance Policies andinvestment 111 any

~\L- l\)'\l- N\L ~\\.__ ~\L N\LFinancial instruments in .Post office or Insurance rCompany and the amount

,(v)" Personal loans/advance

given to any person orentity including firm, ~'L~\\_ N\L N'L 'N\L 1\\\ Lcompany, Trust etc. andother receivables from ., ,debtors and the amount.

(vi) Motor Vehicles/Aircrafts/Yachts/Ships (Details of

N\L N\\.. N\L N'lMake, registration ~\L. NILnumber. etc. year ofpurchase and amount)

(vii) f Jewellery, bullion andvaluable thing(s) (give NY\_, N\L N\L N\Ldetails of weight and NIL N'Lvalue)

t,I

\

(viii) Any other assets such asvalue of claims/interest r\l\L N) 'L t\}, \., 'f\.J \ l_ N'l-- t\}IL

f

. (ix) Gross Total value ; ~I~ ~\\:_ ~\'-- 50,1nSl1 r- N'L r-J1L>•

B. Details oflmmovable assets:

"Note: 1. Properties in j~fintownership indica~ing'tHeextent of joint ownership will also haveto be indicated.

Note: 2. Each land or building or apartment should be mentioned separately in this format., '

,

,

INote: 3. Details should include the interest in or 0 vnership of offshore assets.

S.No Description Self Spouse HU Dependent -I DependentkZ Dependent-3, , ,(i) Agricultural Land ~~;. -

~lN1L NYU ~VL.Location(s) '11~ 'NYLSurvey number(s) ~~Jlh\4\.11~1

Area (total f-~-"" (\_),tmeasurement.in acres) 13:~.o. turL ~ It, '{\j\\..--- N-'VL, , , I

Whether inherited

N{L Iproperty ye! NIL NIL ~'L N-VL(Yes or No)

Date of purchase in

N-Jcase of self - acquired~O ~\l N l (i\J\L f\jiILproperty I .

ICost of Land (in case ofpurchase) at the time of t\lu f\)\L N\\ ~\_\.- 10\\_ N\AJpurchase

,! , , ' .1•

Any Investment on the \

land by way of NO r0 \ldevelopment, ~\L r0~L f0},\:_ t-J\~construction etc., , ~ ,Approximate Current ~ f0\Lmarket value fIJ'iI

IL N\L N\L, ~\ '10\L M,0\\11)'

(ii) Non-AgriculturalLand

~)\J_Location(s) M'l N\l. ~\L ~lL JJ'lSurvey number(s)

Area (totalN\L 1\JILmeasurement in sq. ft.) N\L }\1~L N\L N~

Whether inherited ~fL 0\~property yV\L ;jlL l\)lL IV {L(Yes or No)

I

~,rih

..

Date of purchase incase of self - acquired . I\)\L,...l\L NI\..._ J\)'\._ I\JtL tVlLproperty

Cost of Land (in caseof purchase ~at the time

~\L l\)t\__ rJtL NIL NIL Nt Lof purchase I

Any Investment on theland by way of

'l\Hl t\J\ L I\J\L NlL N\L.development,' . ,Nilconstruction etc.

,

Approximate current.market value .. N\L Nfl }J\t- N\ t. t\J\L N\LI

(iii) Commercial BuHdinl,!s

, (including apartments).~It tJ\L '~'l N\L Nt\,- tJ fl'-Location(s)

-Survey number(s)

IArea (total ,measurement in sq. ft.) NIL N\L NIL N\L t\J\l- NIl-

.. Built-up Area (total,N\ lNlL' NfL f\J\L- ~\L NtL•measurement in sq.ft.)

Whether inheritedproperty N\t NtL Nit N'k N\L N1L(YesorNo)

I Date of purchase in , ., .case of self - acquired 1\),l N\L f0tL 1\HL N\\._ NiLproperty

Cost of property (inI case of purchase) at the

NIL N\L to\L N\L T0\L NILti'me of purchase

, , , Any Investment on the I

property by way ofJ..J \ L NlL MlL N\L NIL /VIL,development,

construction etc.

..

~

,

Approximate current ktmarket value~'L-- ~ ~~\L- NtL

•

(iv) Residential Buildings

•(including apartments):f\JJ L·, -Location (s) , NIL- ~ i\\-~ NvL--Surveynumber(s)

Area (Total, measurement in s,q. ft)

NIL ~\'L' I"\\. ~tL N\L- ~

Built up Area (Totalmeasurement in sq. ft.)

N\L ~ \L NtL NIL f'\WG_NIL

Whether inheritedproperty

N)LN~L N\\_ J\)lL N~L(Yes or No) ',tlDate of purchase incase of self - acquired N,l (\}j\L ~Iu, NIL NfL N\1-property .".Cost of property (in Jlt' case of purchas.e)at the,

NIL N'VL M\L N)L NfLtime of purchaseI

AQ.yInvestment on the JILland by way ofNI\.development, NiL NfL- NfL rN1L

construction etc.\

Approximate currentmarket value ·NILNtL

~'L- NIL NIL NIL,

(v) Others (such as interesttV IL.-in property) ~[L IN IL- l\}u. fJ1L NIL,

~ ~'f.;.. '-,'.;r,

-«:p

/

(vi) Total of current market ~value of (i) to (v) ..,'11

~'l Ntl_, NIL Nfl_,-above ~\ ~\\._is'(8) I give herein below the details of liabilities!dues to public financial institutions andgovernment:-

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

S. No. Description Self Spouse HUF Dependent-l Dependent-2 Dependent-3

(i) Loan or dues to ~e,J?BankIFinancialInstitution(s) ~6f t-Jll i'J'L Nfl_ ~'Lf0\LName of Bank or locJ')Financial Institution,Amount outstanding, ',SO,lti,Nature of loan

Loan or dues to anyother individuals!entity other than

Mil NfL MIL NILmentioned above. N\L tvlLName(s), Amountoutstanding, nature ofloan

Any other liability N'L ~lL "'lL !JtL NIL JJfLGrand total of liabilities

) 5l't61' \~.Jll "'lL NLL Nll J\)(,,-I

ii) Government Dues:

Dues to departmentsdealing withGovernmentaccommodation

(A) Has the Deponent been inoccupati1on of accommodation,provide1 by the Government at anytime d~ring the last ten yearsbefore the date of notification ofthe currclnt election?

(B) If answ1r to (A) above is YES, thefollowing declaration may be~rnishe~ namely:-(I) The address of the

(lJovernmentdccommodation:

·1···················· ..................................

(ii)

YESINO(PI. tick theappropriatealternative)

+~:~ec:s no d~;S paya:~:~:

Government~ccommodation, towards­~a) rent;

~b) electricity charges;I(c) water charges; and

Jd) telephone charges as on. . . 1 (date)

[the date should be the last date of the,third month prior to the month inwhich the lelection is notified or anydate thereafter].

Note- 'Noi Dues Certificate' from theagencies cbncerned in respect of rent,electricityr1charges, water charges andtelephone charges for the aboveGovernmTt accommodation shouldbe submittFd.

(iii) Dues to department dealingwith Government transport(including aircrafts and

- helicopters)

(iv) Income Tax dues

Self . Spouse HUF Dependent-I Dependent-Z Dependent-3

(v) GST dues

(vi) Municipal/Property taxdues

(vii) Any other dues

(viii) Grand total of allGovernment dues

Whether any other(ix) liabilities are in dispute,

if so, mention the amountinvolved and theauthority before which itis pending.

(9) Details of profession or occupation:

(a) Self. AE1~~(-~).~ '"(b) Spouse N\.~ .

(9A) Details of source(s) of income:

(a) Self ......... Au~f.~~.~~\L(b) Spouse ; .

(c) Source of income, if any, of dependents, ~. ~. \:- .

(9B) Contracts with appropriate Government and any public company or companies(a) details of contracts entered by the candidate N\~.(b) details of contracts entered into by spouse :~.~~ ..(c) details of contracts entered into by dependents ..N.\. \-:- .(d) details of contracts entered into by Hindu Undivided Family or trust in which the

candidate or spouse or dependents have interest N.\L ..

(e) de.tails of contracts, entered into by partnejShiP Firms in which candidate or spouse ordependents are partners N.t.~ .

(t) details of contracts, entered into by private companies in which candidate or spouse ordependents have share N. \~ .

(I 0) My educational qualifica lion is as undJ oL. . $..$..f ..~!!I::In~h..$~LY.~nr~ft~..r..~....:...~SL'mJ~

(Give details of highest School/University education mentioning the full form of thecertificate/ diploma/ degree course, name ofthJ School /College/ University and the yearin which the course was completed.)

PART-B

(11). ABSTRACT OF THE DETAILS GIVEN IN (1) TO (10) OF PART - A:

1. Name of the candidate Sh./§n~um. Re)JI , PC\~~ Ct . ,rna to/c;ht\._G t1

2. Full postal address H,ND /- ISb d.!)y\y\tJ( VC\nq<:\YC!\i I'I~3. Number and name of the ptlvla~ ~1'd~a~constituency and State j

4, Name of the .political party which t1",de pe-nJe.f\ rset up the candidate (otherwisewrite 'Independent')

5. Total number of pending criminalcases I'\:,\L

6. Total Number of cases in whichconvicted ('0\L,

7. PAN of • Year for which last Total IncomeIncome Tax Return filed Shown

1\ a) Candidate • N°(JtM4I1otf, ~ N'L N\L-b) Spouse 'n L- N\L 1J1L,(c) HUF NIL l\\ L iJlL.(d) Dependent (\HL rJIL AJlL.

8. Details of Assets' and Liabilities (including offshore assets) in Rupees

Description Self Spouse HUF Dependent-! Dependent-I! Dependent-Ill

A. Moveable Assets'10~1~ tJ\L NrL r;OtOOO/'" N\\.__ NlL(Total value)

B. Immovable Assetsrj(Ibl~ ~'L- rJlL N\L tJ\L N\~

I Purchase Price ofse lf-acq uired NIL MtL NlL tJtL }JILimmovable (\h\_property

II Development/construction cost of

Nil N\L l\J(L tv Itimmovable NfL Nrlproperty afterpurchase (ifapplicable)

.

III Approximate NVLCurrent Market Price N\L fJ\L Nll N\L Nlu-(a) Self-acquired NIL NlL lJ1L NVL

assets (Total N\l. Nll__Value)

(b) Inherited assets N'L rv\l N\l NIL W1~ ~VL(Total Value)

9. Liabilities . 06 ~\LI ~IL #--jt\.._ f\jl\_ J\J-tILJSO,

(i) Government duestJ\L tJ\L(Total) , tJ'\.... ~\L ~lL (\JvL,

(ii) Loans from Bank,~~Financial Institutions l' ~'L Mll fjlL I\HL i\h/L

and others (Total) ! 'O~

·1~110. Liabilities that are under dispute I

(i) Government .dues(Total) fJ\L N1L tJlL. t\?\ L f\?ll V'J\L

(ii) Loans from Bank, I

Financial Institutions (\)\L I'J\L f\) \L /'JIL tv\Land others (Total) JJlL

• I L~I11. Highest educational qualification: >~I~~ttff- t"lSh ~L.kof)'J veJh F='of~ ~'"\A.qd

(Give details of highest School /University education mentioning the full form of thecertificate/ diploma! degree course, name of the School /College/ University and the

I

year in which the course was cornpletedj)

I.\

---~

VERIFICATION

T, the deponent, above named, do hereby verify and declare that the contents of thisaffidavit are true and correct to the best of my knowledge and belief and no part of it is false andnothing material has been concealed there from. I further declare that-

(a) there is no case of conviction or pending case against me other than those mentioned in items5 and 6 of Part A and B above;

(b) I, my spouse, or my dependents do not have any asset or liability, other than those mentionedin items 7 and 8 of Part A and items 8, 9 and 10 of Part B above.

\' .111the I(":f. ......•.......•... dayVerified at thisof ..M~.,. ~ l.~ .

YP,R__~~~/ DEPONENT

Note: 1. Affidavit should be filed latest by 3.00 PM on the last day of filing nominations.

Note: 2. Affidavit should be sworn before an Oath Commissioner or Magistrate of the FirstClass or before a Notary Public.

Note: 3. All columns should be filled up and no column to be left blank. If there is noinformation to furnish in respect of any item, either "Nil" or "Not applicable" asthe 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 Affidavitshould bear on each page the stamp of the Notary or Oath Commissioner orMagistrate before whom the Affidavit is sworn.

(Ministry of Law & Justice Notification No. HII019(4)/2018-Leg.II, dated 10th October, 2018and Notification No. H-ll 0 19/13/20 16-Leg. II, dated 26th February, 2019)

~....1

FORM OF OATH OR fFFIRMATION(To be made by a candidate for election to the Legislature ofa State)

L having been nominated as a candidate to filla seat in the Legislative ~ssembty (*~r .Legislative ~!ounCil)do swea~in ,thename ~ftbe God j

Solemnly affirm that I will bear true faith and allegiance to the constitution of India as by lawestablished and that I will uphold the sovereignty ant integrity of India, ,

p.~~~~~Signature and name in block

letters of the candidateUA ~JHJ.A'Tl~l2Jtm~!. H-)JA .t2.eDvY]

Sworn in the name of God/Solemnly affirmed by SI1!ri/Shrimati , ~ .at , ,....•....~ , (Place) at , (hour) this the .day of .." " 200 before me.!

Signature of authorized person

Name and designation and Seal

(CERTIFICATE FOR RECEIPT OF OATH)(To be handed over to the candidate by thc,'autho'dzedperson)

Certified that (name) a candidate for election to the LegislativeAs.em~lY ('or Legislative Council) bas made and +cribed the oath / affirmation as requiredby the Constitution of India before me at my office atr (hour) on (date).

Signature of authorized personName Designation and Seal

Date:

"Score out which is not applicable. I

N.B.: This Form should be supplied to the candidates both in English and in the OfficialLanguage of the State/Union Territory.

_. -- - --------------------

ELECTION COMMISSION OF INDIANirvachan Sadan, Ashoka Road, New Delhi-I 10001

No. 3/4/201 7/SDR/VoUJ Dated: 1oth October, 2018

re,

The Chief Electoral Officers ofAll States and Union Territories.

Sub:- (I) Supreme Court's Judgmen~on the petition regarding peoplewith criminal antecedents contesting elections;

(ii) Amendments in Form~26(Format of affidavit by candidates).

Sir/Madam,

The candidates at all elections are required to file affidavit in Form-26, along

with nomination paper, declaring information about criminal cases, assets, liabilities

and educational qualifications. Form-26 has now been amended vide Ministry of law

& Justice Notifi<:ation No. H.l1019(4}/2018-LegJI, dated 10th October, 2018. Tile

amendments made in Form-26 are in pursuance of the directtons in the judgements

of the Horr'ble Supreme Court in Writ Petition{C) No. 784 of 2.015 (Lok Prahari vs.Union of India & Others) and Writ Petition (Civil)No, 536 of 2011 (PubliC Interest

Foundation & Or5. Vs. Union of tndia & Anr .). A copy of the said notification along

with a copy of the updated farm-26 is enclosed herewith. The candidates are now

required to file the affidavit in the amended Form-26.

2. In the judgement in Writ Petition (Civil) No. 536 of 2011, the Hon'ble

Supreme Court has, inter alia, given the following directions>

"{i} Each contesting candidate shall fill up the form as provided by the ElectionCommission and the form must contain all the particulars as requiredtherein.

Oi) It shall state, in bold letters, with regard to the criminal cases pendingagainst the candidate.

(iii) If a candidate is contesting an election on ticket of a particular party,he/she is required to inform the party about the criminal cases pendingagainst him/her.

('1)

I

The concerned political party shall b~ obligated'to put up on its websitethe afuresalGi information pertaining to candidates having criminalantecedents. ~The candidate as well as the com erned political party shall issue adeclaration hi the widely circulated ewspapers in the locality about theantecedents of the candidate and atso give wide publicity in the electronicmedia. When we say wide publiCity,+e mean that the same shalf be doneat least thrice after filing of the nOminrtion papers."

In pursuance of lI1e aooveri>enti""fd judgement, the Commission, after

consideration, has given the folio ing directions to be followed by

(Iv)

3,

due

candidates at elections to the Houses 0 Parliament and Houses of State

Legislatures who have criminal cases against them, either pending cases or cases

of conviction in the past, and to the pollticai arties that set up such candidates :-I '

{a) Candidates at elections to the Hou~e of the People, Council of States,

legislative Assernblv or legislative counrH who have criminal cases against

them - either pending cases or cases in fhkh candidate has been convicted,

shall pubUsh a declaration about such cases, for wide publicity, in newspapers

with wide circulation in the constituenfl y area. This declaration is to be

published in Format C-l attached here 0,. at least on three different dates

from the day following the last date for jithdrawal of ca.ndtdatu. r~s and uP,to

two days before the date of poll. The matter should be published In font size

o~ at:east 12 a.".d.,ShO.....~.I~ be Plac. ed ~Ui~bIV.~n.t.h,enewSP3.p.'~rsso that thedirections for Wide publICity are complied iWJth In letter and spmt.

(lII~stratjan: If the last date f~r :VithdraWf! is ~oth of the Month and poll is on24 Of}he.,MO.nth '. the publishmg of deGraratlon shaJl be done between 1i"and 21 fJ of that Month).

[b] All such candidates with criminal cates are also required to publish the

above declaration on TV channels on I three different dates during the

abovementioned period. But, in the case of the declaration in TVChannels,

the same should be completed before th~ per!.od of 48 hours ending with the

hour fixed for conclusion of poll. I

2 I

I

I

(c) In the caseof all candidates who have criminal casesasper the declarations

in Items 5 and 6 of Fom-2oi the Returning Officer shaltgIve awritten reminder

about the directions herein for publishing declaration about the criminal cases

in newspapersand TVchannelsfor wide publicity. A standard format for such

reminder to the candidates is annexed as Format C~3. The candidates shall

submit the copiesof newspapers in which their declaration 'in this regard was

published to the District Election Officerl along with their account of election

expenses.

Ie) In the case of candidates with criminal casesset up by political parties,

whether recognized parties or registered un-recognized parties, such

candidatesare required to declare before the ReturningOfficer concerned that

they have informed their polltical party about the criminal casesagainst them.

Provisionfor suchdeclaration hasbeen made In Form-26 in the newly inserted

Item (6A).

4. The Political Parties- recognized parties and registered un-recognised

parties,which set up candidateswith criminal cases,either pending casesor cases

of past conviction, are required to publish declaration giving details in this regard

on their website aswell as in TVchannelsand newspapershavingwide circulation

in the State concerned. This declaration by political parties is to be pubUshed in

Format (·2J annexedhereto. Publishingof the declaration in newspapersandTV

channels is required to be done atieast on three different dates during the period

mentioned in Para-2(a)above. In the caseof TV channels, it shall be ensured that

the publishing should becompleted before the period of 48 hours ending with the

hour fixed for conclusion of poll for the election. All such political parties shall

submit a report to the Chief Electoral Officer of the State concerned stating that

they have fulfilled the requirements of these directions, and enclosing therewith

the paper cuttings containing the declarations published by the party in respect of

the StatejUT concerned. This shall be done within 30 days of completion of

3

efection. Thereafter, within the next 15 da~s} the Chief Electoral Officer shouid

submit a report to. the Commission conrming compliance by the parties

concerned, and pomttng out cases of defaUlt].rs, If any.

5. It may also be noted that the pr01iSionsfor the additional affidavit in

respect of dues against Govt. accommodatio . # if any, that may have been allotted

to the candidates, have now been incorpora ed in Form~26 itself under Item (8)

relating to liabilities to Public Financial Ins~itutlOnS and Govt. Therefore, the

candidates shaUgive the requisite declaratio~/particulars in thts regard in item (8)

of Form-26. Accordingly, the candidates are n .w not required to file the additional

affidavit prescribed under the Commission's rder No. 509/11/2004-JS~I,dated 3rd

February, 2016, as the provistons are now pa t of Form-26 itself.

I •

6. This letter may be circulated to all oEOs, ROs in the State/Union

Territory for necessaryaction on their part. This shall also be circulated to aUthe

political parties based in the State, l.e. the Sta~eUnits of the recognlzed Parties and

reco,gni2~ State parties of other States and til r~gister.,d un.re.co~nizedP.Olitk31

parties With headquarters based10your State(Unton Terrttorv, WIth mstructlons to

take note of the above directions and the amkndments in Form-26.

Yours faithfully,

~(KJ·"'.WILFRED),

Sr. PRINCfP AL SECRET ARY

7. Pleaseacknowledge receipt and co firm action taken.

4

Format C-1

( jor candidate to publish in Newspapers, TV)

Declaration about criminalcases

(Asper the judgment dated 25th September, 2018~of Hon'bteSupreme Court In WP(Civil) No. 536 of 2011 (Public Interest Foundation & or« Vs. Union of India &Anr.)

Name and address of candidate: _

Name of political party: ~~---~-- _(Independent candidates should write Nlndependentll here)

Name of Election

*Name of Constituency: _

(name of candidate), a candidate for the

abovementioned election, declare for public information the following details about

my criminal antecedents:

NameCourt

Pending criminal cases Details about cases of convtcttonfor criminal offences

~f !Case No: and I secnonls) of Acts

I status of case . concerned . andI Ibrief description ofI 1 offencels)

!1

Descriptionoffencets)punishmentimposed

of&

Name ofCourt &datets] oforderlsl

"'In the case of election to Council of States or election to Legislative Council byMlAsl mention the election concerned in place of name of constituency.

Note: (i) Details should be given sep.orf1telyfor each case in separate rows.(iiJ Thematter in newspapers should be infont size of atleast 12.

5

FormatC~2'

.. (For pelitiad pai to publish in website, newspapers, 1V)

Declaration about criminal antecedents of candidates set u b, the art

(Asp.erthe judgment dated 25thSeptember;2018 Gt/ (Jft'bleSupremeCourt in WI' (Civil)No. 536 of2011 (PublfcIMerest Foundation & Ors. Vs.Union of In ia &.Anr.)

Name of Political Partv: ~ _,__ ~. .._

#> N-am-,e-of-EI;CUon : 1------ ---~--~--------~+-~~--------Name of Statel UT : -+1 _

I

~-t--N-a-m-'e-2--0-f +-N-am-,,-e-3_-0-f-1-p-e-n-d-in-g-C-r.-4rr+--'I in-a-I-c-a-s-e'~s--,f-lo-e-t-a-ils--a-bo-:-:-c-a-s-es-'-o"""";f

candid~te constituency I conviction for criminalNo. offences

Sections of~he ActsJ~ncerned& briefdescription4f1ffenCe{S}

Name ofCourt,case No.&. statusof thecase{'S)

Name of Description ofCourt &. offence{s} &.date(s) of punishmentorder(s) imposed

~,~.~--.~~I~t_--~_~j

*In the case of election to Council of States or election to legislative Council byMLAs, mentioA the election concerned in. place of name of constttuencv,

Note» (I) The above in,1orm,at,iofl Sh"all be,pUblil,hed State w, ise for each Statel, UT.

(Ii) TIle matter in newspapers should be rbiiShed in font size of at (east 12.

6

.'

FormatC..3

Office of Returning Officer

Name of Constituency

Name of State

Name of Election

It is informed that as per the judgment dated 25tll September, 20181 of Hon'hle

Supreme Court, in WP (Civil)No. 5.3oofZ(JIr{pUblit Interesffoundatior'i &O.rS;Vs-;-Unionof

India & Anr" and the directions in the Commission's letter No. 3/ER/2018/S0R I dated

10-10-201S, all candidates with criminal cases- either pending casesor casesof conviction in

the past, are required to publish declaration regarding such criminal cases 10 newspapers and

TV channels on three occasions during the period from the day following the last date for

withdr;lwal of candidature and two daysbefore the date of poll, Publishing declaration in TV

channels should be completed before the period of 43 hours ending with the hour fixed for

conclusion of poll.

Since you,ShiilSmt./Ms. ----(,Mention the nameof the

candidate}, a candidate nominated for the abovementioned election, have declared

information about criminal cases in Items 5/6 of Form-26, you are required to publish

information in newspapers having wide circulation in the constituency area and on TV

channels onatleast three occasionseach asmentioned above. The Format for publishing the

information is enclosedherewith. It isalso informed thatcopiesof the newspapers publishing

the information about criminal cases should be submltted to the Djstrict ElectionOfficer along

with the account of e~ectionexpensesunder Section 78 of Representation of the PeopleActl

1951.

Date: Signature, -

Nameofthe RO/ARO _

Signature of Candidate _

Note: One copy af this should be given to candidate and one copy retained with RO.

7

·, '

ELECTION COMMISSI N OF INDIANirvachan Sadan, Ashoka Road, NjW Delhi -110 001

No.3/4/2017ISDR Vol-II I 'Dated: 05th November. 2018

To,

The Chief Electoral Officers of1. Chhattisgarh2. Madhya Pradesh3. Rajasthan4. Mizoram5. Telangana

Subject: '. FAQs on Criminal Antecedents, if any. of a candidate and its publicity in pursuanceof Hon'ble Supreme Court Judgment dat1d 25/09/20 IS in (C) No. 536 of 2011regarding I

IJ am directed to invite your reference to the Cojission'S directions in letter of even No.

dated IOtIO/20IS issued in pursuance of Hon'ble Supre I e Court Judgment dated 2510912018 in

(C) No. 536 of 2011. In view of the various queries rJised in this regard, a set of FAQs and

clarifications in this regard is enclosed. . I2. The FAQs may be circulated to all DEOs, RC/tUrning Officers, officers connected to

elections and the Political Parties based in your State, for their information.3. In the Commission's abovementioned letter, it has been inter alia, directed that after the

election the candidates shall submit a report about publJhing of declaration to the DEO and the

Political parties to the CEO of the State. The commiSSi1n has provided formats C-4 and C-5 for

this purpose. The formats are also enclosed. These shall 150 be circulated to the DEOs, ROs and

Sir.

all political parties based in the State.

Yours ~ilil~IY, ,

(N.T~utia)Secretary

II

ICopy to: All Recognized National and State Political PrieS

I

, .

FAQs : Criminal Antecedents, if any, of II candidate and its publicity inpursuance of Hou'ble Supreme Court judgement dated 25-09-2018 in WP(Civil) No. 536 of20U.

Q.l Which newspapers are to be chosen for publicity by such candidates?

Ans. As per direction in the judgement of the Hon'ble Supreme Court, thedeclaration is required to be published in newspapers with wide circulation in thearea concerned. The CEO may get an in<Ucative lis! of various newspapers whichhave wide circulation in the various district/different constituency areas in the Stateprepared by the State DIP. This ~~ list should be shared with the politicalparties and the candidates.

Q.2 When has it to be publicised?

Am. It has already been clearly mentioned in the Commission's letter dated10-10-2018 that the publishing has to be during the period starting from the dayfollowing the last date for withdrawal of candidature and up to two days before thedate of poll.

Q.3 There is no column for signature. Who will authenticate it?

Ans, The format contains column for mentioning the name and address of thecandidate and the name of the political party on the top portion of the format. Thus,the name of the publisher will be clear from the declaration. There is no need forpublishing the information with the signature of the publisher.

Q.4 What if someone publishes false information about crimina! cases of anothercandidate?

Ans. There are already provisions to deal with any case of publication of falsestatementin relation to a candidate [Section 123 (4) ofthe RP Act, 51 and Section1710ofIPe].

Q.5 Which TV channel the declaration has to be publicised?

Ans, Please refer to the answer against Q.l above. It has to be done in TVchannels which arc available/popular in the areas concerned.

Q.6 What will be the font size and duration of pu licity in TV?

.-

Ans..Font size should be the standard size used 1'0 displaying printed material onTV. Its duration may ll.otbe less than 7 seconds.

Q.7 If a candidate does not have any criminal record, whether he/she is required topublicise? I

Ans. No. Only those candidates Who. have ei[he~ pending criminal cases or whohave been convicted in the past are required to publish the declaration.

Q.8 Wh.etbcr FIR cases have to be published OrI the concerned candidates ~dpolitical parties? .

Ans, Yes. Under the heading' Case No. and statuJ of case', details regarding FIRs,mentioned in Item-S of Forrn-Zfi, are required to bf mentioned.

Q.9 If after filing nomination, status of criminal case changes, whether candidatecan revise the details? . I

Ans, It will be open to the candidate concerned tf notify the revised status to theReturning Officer and to publish that revised status only. If it is NIL, the candidateis not required to publish it. I

Q. 10 Who will bear the expenses for publishing?

Ans. Expenses, if any, will be borne by thecandidate and the political parties inrespective cases. I .

Q. II Whether expenditure on this account will1accounted for?

Ans. Yes. This being an expenditure in conncctiop with the election, if expense isincurred in this regard, the same will be counted! for the purposes of election.

Q.12 c~ RO act on any discrepancy in ~UCh de,IS if pointed outv .

Ans. No. RO IS not supposed to enquire into corr1ctness of declarations publishedby candidate/political parties.

Q.l3 In what manner, such candidates will submit the information about publicityof cases to the DEO? I.

II

I

I

I

I

Format C-4

Report by Candidate about publishi.ng of deciaratlon regarding criminal cases

Name <lmfaddress of candidate: ----

Name of political party: _(Independent candidates should write 'Independent' here)

Name of Election

"Name of Constltuencv: _

___ . ~ (name of candidate), a candidate for theabovementioned election, certifythat I have published the declaration about my criminalantecedents in newspapers and TV channels as per the directions of the E!ectionCommission in pursuance of the judgment dated zs'' September, 2018, of Hon'ble SupremeCourt in WP {Civil} No. 536 of 2011 (Public Interest Foundation &Ors. Vs. Union of India&'Anr.). Details are as follows:

fSI·------· Newspape-r --_·-1····

~. Name of Date 0

I Newspaper publishing

II j

1 II i _._._.,--_ _.._+--_.-+-tL_ ........,......·_·j_

I Mode of lPaym<>nt

Television

I~ {

(electronic/cbeque/

! DO/Cash)

- (PI. specify)

f Expenses Name of Date &. time of Expensesthat may channel insertion/telec that may

I

have ast have1 been been

I incurred I incurred](in Rs.) in R5.)

I I-r--"-" ,. ....- f---

I

-_..._- _jCopies of newspapers in which declaration was published are enclosed,

Date:- Name & Signature of Candidate

Note:-(i) In case of elections to the Lok Sobna and the Legislative Assemblies, this shall besubmitted alongwith the account a/election expenses,

(ii) In case of elections to the Rajya Sobha and the State Legislative Council, this shallbe submitted to the Returning Officer concerned within 30 days of declaration of result ofelection.

Ans. Separate formats have been specified by the Commission for the candidatesand the political parties to submit report about publishing of the declaration. Theseare Format-Ceq for candidates and Format-CvS for rlitical parties. '"

0·14 What happens If such candidates or such polplcaI parties do not publicise In

the manner prescribed? I

Ans. Such failure may be a ground for post-electioh action like election petition orC.9ntcrt1ptgf Hon 'ble Supreme Court.

\ -

Format C-5

Report by Political Party about publishing of declaration regarding crimi!;lal cases

Name of political party: _

Name of Election

It is certified that (name of political partvihas

published the declaration about the candidates with criminal antecedents on the website of

the party, in newspapers and TV channels as per the directions of the Election Commission

in pursuance of the judgment dated zs" September, 2018, of Hon'ble Supreme Court in WP

ICivil) No. 536 of 2011 {Public Interest Foundation &Ors. Vs. Union of India &Anr.}. Details

are as foliows.-

.~- ..-.- ..¥~----.--- ISI Website NewspaperNo.

I'-'''--1~'

Date(s) of Name(Period Name(s) of Expensesduring Newspaper publishing incurred I ofwhich (in Rs.) chaondisplayed l

E --- jI

- -.~..

-..-~.

.._----_._. __..__ .._._..,..-----,i Mode of• Payment(electronic/cheque/DD/Cash)(PI. specify) .

I I

Television

5l I Date(s} & time ofinsertion/telecast

e!

Expensesincurred(in Rs.)

I··-·-····------+------J--i_l I ]Copies of newspapers in which declaration was published are enclosed.

Dater- Signature of office bearer : .

Name & designation .

Note>This report shalf be submitted to the Chief electoral Officer of the State within 30 daysof deciorotion of result of the election concerned.

FORM)fSee rule 9(1)]

COJ/dHCI of Elecuons Rules 1')61(Statutory Rules and Or ccl

NOTlCE OF WlTHORAWAI. Of CA DlDATUR£

Electior: 10 the" " .

The Returning Officer,

I, _ .,..".., a '[candidate validlycandidature.

Place ." ...•........Date .

Signature of '[validly nominated candidate].

This notice was delivered to me at my office at I (hour) 011.. .

(date) by {name), the+ .

Returning Officer.

Date " .

Receipt Jar Notice of Wffllii)awal

(To he handed over to the person deliv Iring the notice)

1[validly nominated candidate] at theby .the+ at my office

•"1'

The notice of withdrawal of candidature by aelection to the* · · was delivered to meat., (hour) on " (date).

Returning Officer..._-_ ..._._------

(I) House of the People from the constituency.

(2) Legislative Assembly from the constituency.

(3) Council of States by the elected members of the Legislative+" of............•... ,., (State). ,

(4) Council of States by the members of the electoral colJegr of.. (Union territory).

(5) Legislative Council by the members of tile Legislative Assembly.\

(6) Legislative Council from 111<: constituency.

+Here insert one ofthe following alternatives as may he appropriate=-,

(1) Candidate.

\ I(2) Candidate'S proposer who has been authorised in writing by the crdidate ro deliver it.

(3) Candidate's election agent who has been authorized in writing by the candidate 10 deliver it.

I Sobs.b~'Noi;fuN() $0 5;,~(F)~cl;l;:;:i-;h;;jii;~:;;;_.gl!$;:J'jr8;1-- --_._L_. ---- -- .

Conduct 0/ Elections Rules. 1961(Statutory Rules and Order)

FORM 6(See rule 9(2)J

NOTICEOF \VlnlDRAWAL OF CANDIDATURES

Electionto the* .

Notice is hereby given that the following '[validly nominated +candidatcj/candidates at the aboveelection withdraw +his candidature/their candidatures today.

Name of '[validlynominated candidate]

Address of'{validlynominatedcandidate]

Remarks

'.,-.-_,

2.

3.

etc,

Dalc .."" ....Returning Officer.

\----:-"'.' ..,..._"., ''''''''''''',''"''''''" ...'''',,.

~Appropriate particulars of the election to be inserted here.+Strike olT the inapprupriate alternative.

Conduct of EleclibflS Rules, 1961(Statutory Rul s and Order)

[See rule 12(1)J

ApPOINTMENTOF jLECTION AGENT

,(~'~~e filled b: the rtl:mi~g"" ._Electian 10 the 'T'. ,.., """'_"'"

To

,...\\

The Returning Officer,

1, , 0L.................. a candidate at the above election do hereby appoint.. of., ns myelection agent from this day at the above election.

Place ..

Slgnature of candidate.Date .

-_ .._--_ _---_ _- _---------.,. __ .__ _-_ ..------ _-_ __ _--I accept the above appointment. I

Place ..Date .

Signature of election agent

Signature and "Seal of the Returning officer: 1

;-~I~reinsert one ofthe following alternatives as may be appro! riate:..=---··----···

(1) House of the People from the constituency.

(2) Legislative Assembly from the constituency.

(3) Council of States by t~:elected members of, tfJ Legislative Assembly of.; ......(State).

(4) Council of States by the members of the electora! college of... ....(Union territory).

(~) Legi\Slative COUJlC~1~y the members of the L~giSlarVe Assembly.

(6) L",,,, ativcCouncil from the ...•.......... ,,,,,,,,,"enl

\

L _..~. ___ _.._.

Conduct of Elections Rules, 196 J(Statutory Rules and Order)

FORl\! JG!.See rule 13(1)]

..A I'POINTMENT OF ELECTION AGENT

Election [0 theU .

I, t a candidate/the election agent of who is a candidate at the above election dohereby '[appoint... (Name and addressj] as a polling agent to attend+ polling stationNo....................... at/place fixed for the poll al... .

Place .Date .

Signature of [candidate/etection agent.

I agree to act as such polling agent.

Place ..Date .

Signature cf polling agent.

Declaration a/polling agent /0 be signed before Presiding Officer

I hereby declare that at the above election I will not do anything forbidden by section J 28'1'1 of the Representationof the People Act, 195J > which';' I have read/has been read over to me.

Date !

'il Signature of polling agent.

Signed before me.

Date .Presiding OtTicer.

.-:--:------_._ •.......•... _ .._--_ ..•._----------_._---"To be handed over to the pol! ing agent for production at tbe polling station or at the place fixed for the poll."''''Here insert one of the following alternatives as may be appropriate:-

(I) House of the People from the constituency.(2) Legislative Assembly from the constituency ..(3) Council of States by the elected members of the Legislative Assembly of (State).(4) Council of States by the members of the electoral college-of, (Union territory).(5) Legislative Council by the members ofthe Legislative Assembly.(6) Legislative Council from the : constituency.

fStrike off the inappropriate alternative.t+secuon 128 of the Representation of the People Act, 1951:-

" 128. Maintenance ofsecrecy of 1"OIing.-(1) Every officer, clerk, agent or other person who performs any duty inconnection with the recording or countingof votes at an election shall maintain, and aid in maintaining, the secrecyof the voting and shall not (except for some purpose authorised by or under any law) communicate to any person anyinformation calculated 10 violate such secrecy.

(2) Any person who contravenes the provisions of sub-section (!) shall be punishable with imprisonment for a termwhich may extend to three months or with fine or with both."

No.II·II019/0412018-1,~gJfGO\!t:mUl\'~lltor 1l~1din ~

Ministry of Law anli JW;lICC.1.~~i;lativer~parl~nl,.'l1(

****

The MullttgerGnvcmment oflnu.t{l Pr~.ss,May.tpuriRlll,g Road, New Delhi

Sui*ct: Publicati(m or Nmilil:alion in the (iazclh: Ill' Indl~, Extraurdin'll). Part If Section 3,Sub·scctkul(ii)dah':u IO/!(},':!Olg.

Sir. 1J am direct.:d to !tlr\\:lfU her~wi{h a notjli~"itj 11 bearing No.H.1IOIWO.J,:Wf8-LegJJ

daled 1011(J/.:!O18 (ill English and IlinJi) to bl..'!published in the liazeths uf Indin,I qr:RmJillar). i>nrtH. Section J. SUhwS4.·l;liull(ii) 011HIP1lJ.201~.

~. son copy of the notilk.lliou 11m;heen C.H~aikd HI llluy-gipprruI-nieJn and it is,,:cl'lifh:d that the S(ltl copy and the hard cup)' of lhe Ilo itkalion is (me unl.!the sarae.

.1. U is r~:qucstl;'dthat 10 copies of UtI! \lIOt4.~ilid nUlilk:ltion mll~ please be sent ttl [hislkpattml.:nt ,IS SQUU as the sam\.: is pubJbhc~L

v°1~lfUIl~.dL niv;ts)

l\(h.!i!i(llial Lt:gl$la rve (\lHndlTell:; 21384603

TO BE PUBLISHED IN THE GAZETTE OF INDIA, EXTRAORDINARY,PART H. SECTION 3. SUB-SECTION (ii)]

GOVERNMENT OF INDIAMINISTRY Of LAW AND JUSTICE

(Legislative Department)

New Delhi, the .:" ... October. 2018.

S.O, -----(E).-· In exercise of the powers conferred by sub-section (3) of section 77read with section 169 of the Representation of the People Act, 1951 (43 of )951). theCentral GovcnUllent~ after consulting the Election Commission. hereby makes the.following rules further to amend the Conduct of Elections Rules. 1961, nmnely:-

L These rules may bt: called the Conduct of Elections (Amendment)Rules. 2018.

(2) Thev shall come into force on the date of their publication in theOnlda1 Gazette.

2. In the Conduct of Elections Rules. 1961 (hereinafter referred to as theprincipal rules), in rule 90. after: serial number 28 and the entries relating thereto. thefiJllowing.serial number and entries shall be inserted. namely>

Telangana : 10~OO.OOO 28.00.000:",

3. In Form16of theprincipal rules--

(A) in PART A-

(I) for paragraphs (5) and (6). the following paragraphs shall besubsriuned. namely>

H( 5) Pending criminal cases>-

(i) I declare that there is no pending criminal case against me.(Tic:k this alternative, (rlhert;· is no crimina! case pfndillg against the Candidateand write NOT APPLICA BLE against alternative (il) below)

OR

9

(ii~ The following crim inal cases "'Ipending 8gBlnSl me:

((I there (Ire pending r:rilnfnal cases (If) r.:linst the ,~andidate, then tick thisallernalit'e and score l?ff ailernulivl! a) (.{h.m.1~.and give delai/.f of all pendil1Kcases in the Table below)

(a) fiR No. with nameand address of PoliceStation concerned

(b) CaseNo. with Nameoftbe Court

Table

. (g)

{c} Sections of <concernedActslCodesinvolved(giw! rIO. vj'fhi! section. e.g.S4't'filJt' ••... "ol/PC.etc.).

(d) ...8:fi~f description ofoftt:nce

Whether ehar,ges havebeen ffumed .(mention rss (0' NO)

If answer against itenl (e)above is YE;S, th~n

Igive th. e date .(}Il whichcharges were framed

Whether any Appeal!Application tor revisionhas been medagainst tbe proceedings(Memion YES(1P NO)

(6) Casesof eonvicrion-.

.. . (i) I d~lare thai I have.net been CO~icled fur any criminal offence.(1 u:/( this aiternattve, (f the caJ'Ididale has JW1 been convicted and write NOrAPPLIC4.BLE: again,vi alternative (if) below) t

OR(ii) I have been convicted fo'r the offe ces mentioned below:

(If lhe. candidate has been (.'Ot1ViCf(!t:1, then li,y< thts allernllJive and score offahernauve (i) above, and give detuilN in the Tabir given below)

10 I

------------------------------~-------. -----

Table

<gl i..Whether any Appeal

I has been, filed against! conviction order1 (MC'fflion YESor No)I

!---t- .! (h) i If answer to Item (g)

l' ;above is YES~.g. ive details andpresent status

_._~o:.:..r..:;;.ap~p!e=al:..·~._. .__ ....l • ••_J..... _~ -.l.. _

(e) Dates of orders of

(a) CaseNo.

(c) SeerionsefActs/Codes involved(gil't' no. f?f theSeaton;e.g. Seaton ...... til'fPC. etc.

(d) Brief description ofoffencefur which convicted

convictionI; U) ! Punishment imncsed1 I

{6A) I have given full and up-to-date information to my political party about allpending criminal cases against me and about all cases of conviction as given inparagraphs (5) and (6).

[candidates It} whom this item is not app.licable should clearly write NOTAPPLICABLE IN FlEW OF ENTRIES IN PARAGRAPHS 5(1)and 6(i) above.]

Note:

I, Details should be entered dearly and legibly in BOLD letters2. Details to be given separately for each case under d(fforent columns against

each item.J. Details should he given in reverse chronological order. i.e.. the totes: case to

he mentionedfirst and backwards in the order ofdates for the other cases.-I. Additional sheet may he added if required.5. Candidate is responsible fiJI" supplying all in/ormation in compliance of' the

Hon 'hie Supreme Court's judgmen: in W P (el No, 536 of 20} I .";

11

til' in paragraph (7), under the heading .. "Details of movable assets" for'~N()le 4~. the following Note shall be substituted, nan[dY:-

'Nere 4: "Dependen;" means parents. sonts), daugbter(s) of the candidate orspouse and any other person related to the candidate whether by blood or marriage, whohave no separate means of income and who are d pendent on the candidate for theirlivelihood.';

(III, in paragraph (8). in the Table. tor scri,I numbers (ii) to (iv) and the entriesrelating thereto. the fotlowing serial numbers 1101 the entries shall respectively besubstituted. namely:-

"Tahle

l1TIn-OovcmnwlllI f dues:

, Dues 10, Departmentsdealillg withGovcrnmcmaccommodal ion

! fA i BaS the Ocpol1e#~tbeen ill occupation I1 of nc.commod'H~rmprovided by the; Government at Ian)' time during the

Inst ten years Ibefore the date ofnotification of Ihr current election?

(B) tf atlswc.r. to (1) above is YES. thefollowing dt~ltlratjoll may befurnished. namel[\'; .. r

(i) The address I of (he Governmentacconul1odat~on:

~-----~.--.--.--·I~·~---···-·----··.

-:~::::=:::=:::~:::J:::=:=:~::=::::::I

(ii) There is nu d:ue~payable in respect ofllbove Govemfnem accommodation.(owarth I

tal rent;(b) el.ecl.(iei. ty c~a.rgcs;.(e) water chafg~s: andid) telephone bharges as on --.--.-

(date) I

{the date $h:O~lidbe the last date ofthe third mOl11h prior to the monthin which the electien IS notified or

J N~- -:: d::~rer::;~... from,he11' ag.,'.en..cies cone.erned I In respect .Of rent,electricil>' charges, water charges and

i felepllone charges I for the above jh

~ ~~I_G_o_v_e~_._~_~._IlI__ a_e_C_()n_llll-0-da~t_jO_n__ S_hOU__ ld~_~_~ .I SUbmllti;U.I

1.2

, I

(iii) DuestoDepartmentdealing withGovernmenttransport(includingaircrafts andhelicopters)

Jiv) Incometlt'\ duesSelf i Spollse Dependent Dependent Dependent-

! -I - 2 :3r:--::---- ----.----.-.---t-.--f--,----I-----t-----t-------j(v) .GST Dues

(vi) I Municipal? IProperty lUX dues i

t-(-vi~i)-l.AI;YothC;~- , r-----+---·---t----+----------t

~~~ __----~~~~--4_.----~------~~------~--------~! (viii) Grand rota! of all ii Govermnenr Ii dues . .. , . -, ..w ••L---t--~....----r,----,.-'"t__~----+------iI Whedlt'f anv II other liabilities I1 arc in dispute, if I'I so. mention the',' amounT iIWol"Cd,. !, and the authority II before which it is Ip~_pdi!!&::~--. .J _

~'(9A) Details of sources of income:

j

(IV) after paragraph (9). the following paragraphs shell he inserted. namely.-

(ix)

(a) Sci f ------.~------- ------­(b) Spouse --------------------('c) Source of income. if any, of dependents. -.----------

(9B) Contracts with appropriate Government and any public company orcompanies-

(a) details of contracts entered by the candidate ---.........---- ..--(b) details of contracts entered into by spouse ------------(c) details of contracts entered into by dependents --------- __(d) details of contracts entered into by Hindu undivided family or trust

in which the candidate or spouse or dependents have interest ------... --- ... _ .... ----"..''''"'.,., ..,.,." ... ------ __ ~.->fJ"_

(e) details of contracts. entered into by Partnership Finns in which'candidate or spouse or dePC'nrents are partners ~..._._~._.~ __•__ . _

(I) ;';:;:-:;':,;;:':-~tered 1;,"'0 by private. companies inwhich.~~~~~~~_~~~~~_s:;or~rhave share •••---- .... -.-.- ••

(8) in PART - B. in paragraph If againsl serial number 5 and. 6~ for theentries Under column 2. the following entries shaH·! e substituted. namely»

" I

·'S.6.

[F.No. RI HH9(4)120JS ..Leg.H]

~.~

(Dr, R~etaVasishta)Additional Secretary to the G(,}vemment of India

Note: The principal rules were published in {be G eue of India vide number S.O. 859.dated the !SlhApril. 1961 and were last amended vi c number 8.0. 1B3{E), dated the ~IlApril, 2017.

14