Annexure-I Affidavit to be furnished by candidate along with nomination paper Before the returning Officer for election to ............................................................ (Name of the House) from ..................................................................................... constituency (Name of the constituency) I, ..................................................................................................................................................... son/ daughter / wife of .................................................................................................................. aged ...................... years, resident of .............................................................................................. candidate at the above election, do hereby solemnly affirm and state on oath as under :(Strike out whichever not applicable) (1) The following case(s) is /are pending against me in which cognizance has been taken by the court : (i) Section of the Act and description of the offence for which cognizance taken: (ii) The Court which has taken cognizance: (iii) Case No. : (iv) Date of order of the Court taking cognizance: (v) Details of appeal(s) / application(s) for revision, etc., if any filed against above order taking cognizance: (2) That I give hereinbelow the details of the assets (immovable, movable, bank balance, etc.) of myself, my spouse and dependents *: A. Details of movable assets. (Assets in joint name indicating the extent of joint ownership will also have to be given) S..No Description Self Spouse(s) Name(s) Dependent-1 Name: Dependent-2 Name Dependent-3 etc. Name (i) Cash (ii) Deposits in Banks, Financial, Institutions and Non- Banking Financial Companies (iii) Bonds, Debentures and Shares in companies (iv) Other Financial instruments NSS, Postal Savings, LIC Policies, etc. (v) Motor Vehicles (Details of make, etc.) (vi) Jewellery (give details of weight and value) (vii) Other assets, such as values of claims/ interests Note: - Value of Bonds /Shares / Debentures as per the latest market value in Stock Exchange in respect of listed companies and as per books inthe case of nonlisted companiesshould be given. 2 Dependent here means a person substantially dependents on the income of the candidate. B. Details of Immovable assets. (Note: Properties in joint ownership indicating the extent of joint ownership will also have to be indicated) S.. No Description Self Spouse(s) Name(s): Dependent-1 Name: Dependent-2 Name: Dependent-3 etc. Name: (i) Agricultural Land -Location(s) -Survey number(s) -Extent (Total measurement) -Current market value (ii) Non-Agricultural Land -Location(s) -Survey number(s) -Extent (Total measurement) -current market value (iii) Building (commercial and residential) -Location(s) -Survey /door number(s) -Extent (Total measurement) -Current market value (iv) Houses / Apartments, etc -Location(s) -Survey /door number(s) -Extent (Total measurement) -Current market value (v) Others (such as interest in property) (3) I give herein below the details of my liabilities / overdues to public financial institutions and government dues: - (Note : Please give separate detail for each item) S. No Description Name and address of Bank / Financial Institutions(s)/ Department(s) Amount outstanding as on ............... (a) (i) Loans from Banks (ii) Loans from financial institutions (iii) Government dues (a) dues to departments dealing with government accommodation (b) dues to departments dealing with supply of water (c) dues to departments dealing with supply of electricity (d) dues to departments dealing with telephone (e) dues to departments dealing with government transport (including aircrafts and helicopters) (f) other dues, if any (b) (i) Income Tax including surcharge [Also indicate the assessment year upto which Income Tax Return Filed. Give also Permanent Account Number (PAN)] (ii) Wealth Tax [Also indicate assessment year upto which Wealth Tax return filed]. (iii) Sales Tax [Only in case of proprietary business] (iv) Property Tax. 4. My educational qualification are as under: - (GIVE DETAILS OF SCHOOL AND UNIVERSITY EDUCATION) (Name of School / University and the year in which the course was completed should also be given) DEPONENT VERIFICATION I, the deponent abovenamed, do hereby verify and declare that the contents of this affidavit are true and correct to the best of my knowledge and belief; no part of it is false and nothing material has been concealed therefrom. Verified at ....................... this the .................. day of ............................... 2004 DEPONENT
