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Affidavit to be furnished by candidate alongwith 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) I have, in the past, been convicted of a criminal offence in the following case(s)
and the details are as under:-
(i) Case No.
(ii) Section of the Act and description of the offence for which convicted :
(iii) Date(s) of conviction:
(iv) Court(s) by which Convicted :
(v) Punishment imposed (indicate period of imprisonment awarded and / or
quantum of fine imposed) :
(vi) Details of appeals / revision, etc. filed against above conviction(s) :
(2) That I have in the past been discharged / acquitted in the following cases :-
(i) Section of the Act and description of the offence with which charged :
(ii) Case No. :
(iii) Name of the Court by which acquitted / discharged :
(iv) Date of acquittal / discharge :
(v) Details of appeal(s) / application(s) for revision / review, if any,
filed against above acquittal / discharge :
(3) That I have, in the period ending six months prior to the date of filing the present nomination, been accused of the following offences, punishable with imprisonment with two years or more, and in which a charge has been framed or
cognizance taken by the Court as indicated hereunder:-
[Note: This excludes the cases mentioned in (1) and (2) above.]
(i) Section of the Act and description of the offence with which charged /
cognizance taken :
(ii) The Court which has framed the charge / taken cognizance :
(iii) Case No.
(iv) Date of the order of the Court framing charge / taking cognizance :
(v) Details of appeal(s) / application(s) for revision, etc., if any,
filed against above order framing charge / taking cognizance :
(4) 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)
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Sr.No
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Description
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Self |
Spouse(s) Name(s) |
Dependent-1 Name |
Dependent-2 Name |
Dependent-3, etc. Name |
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(i) |
Cash |
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(ii) |
Deposits in Banks, Financial Institutions and Non-Banking Financial Companies |
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(iii) |
Bonds, Debentures and Shares in companies
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*Dependent here means a person substantially dependents on the income of the candidate.
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(v) |
Motor Vehicles (details of make, etc.)
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(vi) |
Jewellery (give details of weight and value)
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(vii) |
Other assets, such as values of claims / interests |
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Note : Value of Bonds / Shares / Debentures as per the latest market value in Stock
Exchange in respect of listed companies and as per books in the case of non listed companies should be given.
[Note : Properties in joint ownership indicating the extent of joint ownership will also
have to be indicated]
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Sr.No
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Description
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Self |
Spouse(s) Name(s) |
Dependent-1 Name |
Dependent-2 Name |
Dependent-3, etc. Name |
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(i) |
Agricultural Land
- Location(s)
- Survey number(s)
- Extent (Total measurement) -Current market value
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(iii) |
Buildings (commercial and residential)
- Location(s)
- Survey / door number(s)
- Extent (Total measurement)
- current market value |
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(iv) |
Houses / Apartments, etc.
- Location(s)
- Survey / door number(s)
- Extent (Total measurement)
- current market value
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(v) |
Others (such as interest in property)
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(5) I give hereinbelow the details of my liabilities / overdues to public financial
institutions and government dues :-
[Note : Please give separate details for each item]
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S.No.
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Description |
Name and address of Bank / Financial Institution(s) / Department(s) |
Amount Outstanding as on………..
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(a) (i)
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Loans from Banks
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(ii) |
Loans from financial Institutions |
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(iii) |
Government dues (other than income tax and wealth tax)
(No Due Certificate to be enclosed in case holding or having held any public office) |
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S.No.
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Description |
Details of Assessment
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Amount Outstanding as on ……….
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(b) (i) |
Income Tax including surcharge [Also indicate the assessment year upto which Income Tax Return filed. Give also Permanent Account Number (PAN)] |
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(ii) |
Wealth Tax [Also indicate the assessment year upto which Wealth Tax return filed.] |
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(iii) |
Sales Tax [Only in case of proprietary business]
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(iv) |
Property Tax
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(6) My educational qualifications 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
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 _______, 200__.
DEPONENT
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-----Tirumala Srinivas