MACHAL r n l1AA 585690 PART- IV

FORM OF AFFIDAVIT

Before the District Election Officer ........~~ ..~... ..... , ......... ........ .. (District, State/Union Territory)

Affidavit of I, ..\f:;.~....J.~.......WF .....\fu~l.-...\I'-'~ .~ ... J.~ .... I... ......... ........... ..........~ ....~.ii..~A/O ..... : .. ... .. ~........................ .. ... ....... aged

....~.£..... .. years Rio .............. ~.( ... .~7' . .. .jJ)..................... ~~.~~!~:~:.;-~~;~:~~~~"'!;;~~::~;~..~~ .~/::~I .......'.................. ( 1) That I was a contesting candidate at the general election/bye

House of the People / Legislat~ Assembly of ....H.c......... . .. from

"'k..-::-....~~~... .. Parliamentary/ Asse~ constituency, the result of

which was declared ....1fS'-;...I.~. :-:: .. ~.r.. . :.. .

(2) That limy election agent kept a separate and correct account of all

1Lv.-day of 201 -r-~...before me

(3) That the said account was maintained in the Register furnished by the

Retmn1ng Officer for the purpose and the said Register itself is annexed hereto

with the supp0I1ing vouchers/bill mentioned in the said account.

(4) That the ac ount of my election expenditure as annexed hereto includes all

items of election expenditure incun ed or authorised by me or by my election

agent, the political party wh ich sponsored me, other associations / body of

persons and other individuals supporting me, in connection with the election,

and nothing has been con ealed or withheld/suppressed therefrom (other than

the expense on travel of leaders' covered by Explanations 1 and 2 under section

77 (l ) of the Representation of the People Act, 1951).

(5) That the Abstract Statement of Election Expenses annexed as Annexure II

to the said account also includes all expenditure incUlTed or authorised by me,

my election agent, the political party which sponsored me, other associations /

body of persons and other individuals supporting me, in connection with the

election.

(6) That the statements in the foregoing paragraphs (1) to (5) are true to the best

of my knowledge and belief, that nothing is fa lse and nothing material has been

concealed.

Deponent Solemnly affinned/swom byq »(.1''~l '~'· ... .s.0.~s

·2. '

.' AIIIIC XIII'C~ l5

i

1t------ --- .-- --.-.-.-----"P:-A-:cR::-::T=--_C:- ---------..------- ='1r

.___N_______ Ca_ ·_a lnc· o f thc__n(!idllt~~-____ ShJSllltJ ~. ViJd-'t l.-~ ----., II Number alltl namc () rCon~ tittl cl'lcy \1- , ~' 1l~

~~~--l Natllr~ of ElcClio,-,-·------­ ..~~~IV

~~ .(please mention whctl,,~rGencrill

Ek<:[ion to State Assclnb'y / Lok Sablia .4s~ . / 1:3~- election) .___ _.__

Date of declaration of rC~lIl(v "'B - !~ - ~,'t- .

n~-S-~, ---- -..... t<.....Name and Address oftlle ElectionVI R . ~--'._~, ({ f ~· I"t.otJc.__Agent

Yf] ' lfGandidiltc is sc't lip by iI politic<lI-­ S<frp.party, Plcasc mcnrioll t~!~ lIalne of the p0.i!.i~~~~__.__...___.___.._.. -1L'_~___ _,._______..____._ Whether lhe party is a recognised YesiNo ~~ical P(lfty ________ ____--'___ _________ ________ .____.

~

Diltc: Signature of tilt: Candidate

Plnec; ~~ , Nmne ViM 'Jr

' , -I , ~

II

III

PAitT-II: AnSTlu CT 0 (s-;~·j.,-'A-l,-·E-.. M--:E.,..N-='T=·O~F-:E-L-.E""C=TION ~-;x PEfI;' i)il~U i~E 0 ';-C-'''-N- ' ­)(-OA:i'E -.-- ­ -. ° 1

._--­ ---­ -----_... ._----- ...._------,-_._-­P~nicill"rs ..\1111. AIlli.

Incurrcd I Auth, by C;mc/idale/ Eicct(lJll

InClIrrC(V

I\ulhorizcd by Pol. P"rly (ill Rs.)

1\",1. Illcurred I ullihori~d (3)+(4)+(5)

, b)' others

I (ill l{s.) ;

_.___ L.,-­ _ _____ 5 ! 6

, i2~G1'7~

r

, , .. ,

, ', :

.,

- ---

--

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Schc<lulcs- I 10 C): DCIails of ~:Icl'!iolls Fu uds lin d Expcu<litlll'C of C illididnlc

'''~'':.-""''' rh;;;;;;;;"", 0.,,1'""'''" "r,h, PoJir',,' p,;~~ jSCllCdlllc­ , --------.~ .. Expenses in public IlIccling, rally, pru- -­-_. '''' ':,~,.S. Nt) Na lmc of Expendilur"

--. -._--­ _.--.-.­I 2 ~.---. ------.­I Vehicles for transporting vis; --' -~-

lors

ni~I~'::~.~:I.:~~~:, poles ctc.'2 Erl'cting Slag"', Palldal & Fur -3 Arches &. Omricades erc.

<I fIQ\\'crsl garlands ---. - -----~ -5 Hiring Loud sp~akcrs. Microl - - -(,

7 - -8

9

--­10

II

12

Posters, haud bills. pamphlets

l3evcragcs like rea, Warer, co --_._ - --Digltnl TV -bourds flisp[ay, display

-Expcnsc9 on celebrities, payn ),~Illulle.mlion etc. ./..

Illumination it ems like serial .--­ .

Expenses ont)'ansport, Helieopter! a;rcmfl! vchkies/ boats "lc. allY other camp,rigncr other thanchmg,es (for sdf, eclcbi"ity or

S",r Campaigner) --------_.. -.._-----_. Power consumption/ generatQr chnrgcs

- - _ . . ----_._-­IJ Rent for venue

1'1 Guards & security charge!; ._­-- 1---­ -.-------------1­15 OOil\·ding & lodging expenses of self. celebrity, pany

fUllciiollHryor any olher C~1llpaigner ;J\ciuding Star Campaigner _ .­

---.~

16 Oth<!·rs expenses -.. -- -~ '''-'' .. ' .- - -_····_---------1

Total___ L..-._ _____. --­-·---------­--­ -­ .l.......~~H~~n.._"'=

Seherlule- 2

--- --------_.­Expcnclitlil"l' illl'ublic meeting filII)" pi for general party propaganda)- ----­ - - ---_.•._-,. ­

____···

Tutnll\ll1oullt of Expenciiltll"l'E in Rs.

----- .-- ­3

N A _~s;or~--

-

Arnt. AmI. illl'Urr.;\11 illClIlTCd I Auth. by by 1'01. Ca ndidate / P~rty with agen t IHllllC -.-.-----f-­4

-490f -

! - -.- _ _1

:\111t. I incu rred ' by ot il(-l", I

I

6 ==__.-- !I

'

----- -

AmI. By AIIlI. By candidate. Pol. Party

I "gmt ..-­ - -f--­ -

.2).)­ .._---_

..+-,---,-1----....

:d~':~ . ~=~~~:=:=~- _~-=':~"1>. m_ .. _ -. -'-.~j D~lOils ~f expenditll},? .on cmnpaignlllatcriHls, like hand?ills, p!llllph,lclS; posters,. hoardings, banner:;. ll -outs, ~atts & arches, Vidcnl Iand audio cassettes, CDs! DVDs, LOlld speakers, amplJllcrs, cligltal IV, bOil\'d dlsjllny , J D (lisplay el . for ca llclldnte ' selecll.o1l

(alnpnigll ( i.c.: other than fho:;c c.ovcretl in Sch<ldulc- 1&2_)_ ____. _. _ _____ ___ _ _ _ . I S. No. Nature of Expenses Total Amount ill Rs, $OlllCCS of Expwciillilc l Remarks, if any !

. . I

Anll. By others

--- -_.•._ - ----_.. f---­2 6

rl- m~~~... ._ :J- "J-~ t?CP- ~=~ ...._--\- ---­

; - -- f--------- - ---... -.---.....---.-- - - .--- -- --.-. ~ -- .------ --j " -'-- --- - - ------ _ ._ - - ---­

1_'1_·0_1,_11 ____.___ · J_._~______ _ Sdlctlllle- 4 .._ - -----_.- - ----._- - ---_...._._-_. Llel~ils of expenditure .on campaign through prinl ~nd electronic media including cable network, bulk SMS or intcmel 'or goci~1 media, new s itemsnV/rndio channel ctc., including the P'lici news so decided by MCMC 01' v.oluntarily tl<linittcd by thp cnlldidnte. Th e derails· sl10uld includc the cxpenditure incurred .on nil Stich news ;,etos <I[lpearing in privately owned llelVs[lapersiTV"",dio

S. Nn Date aild Vcnue N~rnc Of~~!<II. ·--~1Il01IlH or Expenditure 011 public [llcding Call1p,,i gncr(s) & Nalll~. rally, procession etc. with tile Star orPnrly r:;\ll}paigncr(~) apportioned to the ca lJdidill~

(A ~ other than for geil cr~1 pmry propag<l fl dil) in Rs.

1----------------+------- ­ . 2 3 4

Sollife of' E~pendi!lllc

1---'------.--­ ---­ - - - -AI110Ul1t by Amount by AJ1Iount C~lldidfite/Ag~1l1 Pnliti~"1 by Othcl'~

Party

_I

'2 -- - ­

,.jj-:ii/7 ~f/4kT- ~ SN'.,.J·.

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

u..t·~~~ .- ,SfJ'~-· . - --­ _._-_.. ---- ­

- i- ­ --.. .- ­

f---+--------·--·-------+--·-------f--'--·--~--__t ,I

chllllllcis etc.,

S. No NillI!rc ofmccliulll (electroniC! print) 1I1ld riuralioll

.-----.--.--­I 2 .

Naillc and Name and neJdrcss of l'ot~1 Aluount in Rs !.~_~~~e~ ~~~E~:"~;~,~~-=-=~=-address ofOledia agency, reportcr, pi·oviucr (prillt stringer, C(lIllP~IIY or : AmI. 8y AmI. By lelectronic IS.iVJS any persoll to whom Ic<lnctidat.::! Pol. P(,ny / voicel cable dmgcs I COlll111is5 iol1 . Co l. (3) +(/1) ~ ~~cnt TV, social medi~ etc. paid! pay~ble , if : etc .) any I .--- .. .-- .- -...------.- ·--: - --':-- 1----1---- - ­3 '\ 5 . (, 7

..- _.. ---_ .'---- -'

Amt. By uthers

_ .. --­8.

R<ll l1Jrk!;, if allY

---.- ­

.

I I

_...L--_____ L____-L­ _ _.. __ __ . _ ... ._ _, ._- --­ --­ -­---Schedul c' 4A

-O-c-t-"-ils-o-r-e'-xp-c-n-d,i-I,-,re-'o-n-c,,-m-p,-,jg-n -II -lro-lI-gl-I -PI-,it-n-a~I'elc-C-lr-()I-\ic-'-lle-d-iil in ~ luding cable network, bulk SMS'-o-" -in~;,~;-or '-(-":­ia-I ­ .-­ 1 media, news irclldTVlradio 'channel eI C. , incl" fJing the paid news so dec ided by MCMC or voluntarily adlnined by till: candi cble. I The dcl"ils should include the ex penditure in" irred on ali such news item s appearing illllcwspllpcr.;t fVlriulio c hn nn~ ls, oW ll ed by . tite candidate or by the political party sponSClI iug th e candidate. '

S.No. Nall"'~ ofmcdi~lIn Name and ,Na' l'c nnd mldres~Tot 11

(electronic I print) address of IH cdh 'agency, reporter, .. and durat ion pruvider (print ~Irillgcr . ClltllP,ll1), 01' . ll )'

Ielectronic ISM S ~ny person to whom crs I,

I voice! cable charges I COll1l11i,s ill n Col

~ I AmOllnt in Rs. Sources of "xpendilure

AmI. 13 )' -TAII1!. ny " 1111 c~ nc1id"t e/" Pol. [' artv ( lih

. (J )1(.1) gelll

__._.. _._ _ ___ ____.___ . J;j:_~~ II11 Cd i i1 ~:~~ pai dl pily~blc. if . [

I 2 3 14 --­ ...- . . ­- 6 7 8 _ __ __ _ _ _ _ ___ __ c..._ _ _ ___ _ ._ ....l . _____._ ____ _ ____._------­ - - ­-. - -

I ~ .. I

_ ._-­-----­. --­ - •.-.- .----. ~-- ---~~.

2

~-------I-~- -- ·--· - --- ~~I~-·-

-~_rO=-la_I~~---~ ~:~- . ·" i _ SchedUle -5

-- -­---­ --­ ._ .

---­. -

- -- ---­-----­---J

--I

[

-- - - - - --

' - " - '- - tl I I{ ­

S. No Date and Vellue ~;pc;;e-s-o-n-(;1-11 ~-m-ig-'Il-- 'O~I;;~-- G'- -'c-dl e$-" Exp~ncl il'l;;~\Vo-rkcl ;--.~-.-I ' i Il- In Sallr~- o.. -I----r---lNature of R<!iC No. Of' ' au.,. s. AmI. l1y Ami. [l y Aim. By

Expenses' . workers / calldidalel Pol. Pnrty others agents/No. . <tgcnl . ,)fKiosks I ..,------- ­ .- - --.- _.­ ~~.- .

3c3a Jb 62 7 - - --- -.--­ .._ - --­ ._-- ­ ---.

5 ---j--­- ~-------I--

Candidates' baaths(Kiasks) set lip for di~trjbutioll

of vOler's slips -.-­ - -.-. ..·_ - -- -+-- ---+--- - 1- - --- ­2 Cnlnpaigll

warkers hOIiOrarilll11/ salary etc.

· . .- ---­ --_ ··_ 7"j-- - --1 -+---- ----\-- ---1..--­J. Boarding

---. --1----1

~4r~'.,,- - -~;~.-:= ~~- :~~~~- ~-=~=--= Schedn lc· 7-- - - --_._.. - .. ...__.._.._ --_. - - - -- - -_._--- --_.­Details ot'AIMlint or own illl1d used for tile eleclion call\pnign - ..-~-.-.---.~ ...-.--....- --i-- ------,- .._- ---- - -. ­S No. Date Cash DD/,Cil{·,.jl\e lIa. elc. wilh Total Amount inRs. Remarks

details of dr:l.wce bank ' . -----+~---- ---_.__ ._ _. -'._-.. ,----'--- ---'- _. _ - ­

4 5 6

--,-~--f--- • . 9. t>e.?- . =~ 2 . " ­

I~"" -=----= - ~-- --~ ~-:- -- ~='- -I ~==-·= -·-~ ,, tJ~---~= ---~·~· -,---~·~·-~---·~---· - ·~ ~..---... ~-- .-

......_.- ---_...._- _._- ------- ,-----_....__.. _ ._--- --_ .. ----.._--.. Schedule- 8

.__._---_._---- -- ---- ----- - ------ - --- -­Details or LUi\1p SIIlIl amOLlI1t r.:ccived frolll the party (it's) ill cash or cheqLle or DD or by Accoullt Transfer

~5~·~·[Nllmc-·~f tllC---]Datc-------- tIt~..-- rDD! C;;o." '" ,to with "",,,, OiJT~;;;- · 1~t'-IlI-mk~~-Politica l Pml), . IJrawec bunK I if ~Ily

l___ _._____.____ _____ __ ___ _..1..._ ____. ~~ _.~

----"':}z:~ -'

---------.,--­ -.­ _.._- ._--------­ --- ­ollnt ill R~. - ­ ---­ -­ - -- ­ -­ - ..---1----­ -­ -.­ .--..---- '"-----~--- I---..­ ._"

2 ) 4 5 6 7 __~~~ 'iucf'4= 7.,--;-- ­ , -- btl lJ~--/ ­2 --~,-----", . , l' - 0; i' - r - - --.-- .-

1- - - --­-,­.-. - ---'..--.­ ---­3 -- ­ --. --­ ----11-­ - - ­ '---­ - -- ­ ,-----­ - --1-­ - --_._ - -_._- -1--­II

___. __ '" .l._._'_- ' _· --_-...L-_-· _-=--=--=-'~+_-I-£-~-'-/_ ~"D~- - -~' . -~.--

Tot,,1

Details of Lump sum ~ 1l101lnt received from .~ ~)' ptlson/coillpanylfirm/nssoc inti oll s/hody of per~on s etc. ns lonn. gift or l

DOl Cheque no. etc. Mcntion whether wi tll delnils of 103 11 , gin or drawee b;lllk IdOIl" tiOil etc .

'1'01" I A111

OU llt ill Rs.-00-·---------· .. ..... ----.00- . .--­ - ­

5

__-__-I-­_..:f.c.;,'-"tl~

._-,

3

-~"i

--+~?-~-7;J~~·- - -t:;Zi~ =~--~ ~-7~ If' n ''',. ,,-/= - ~

LS""~~~L/_~~~,_.J"r 11: . I~ ~k.---~ =-~~__- --!:-_

'7;,t;;i. . ~ , L-

_ --.J.-r-----NOle: I , In Schedul e 5: ­(~) copy ofl"t order cOlltaining list O'J ' I vehicles ['or whiell permit issued by the Retllrning Officer 0 ' enc losed. (b) Iflile vehiclc is owncd by the can,), daldhi ~ rclalivc/agenl arc used 1'01- eleclion pl11'pose, nOli ol)l11 eo:;! or hir~ uf all sllch veh icles , c.\Cepl one vehicle ifown,!I amj used by Ihe candid~tc, Iloliollal C051orrlld ~nd driwrs ;;"lary lOr ' sli ch vehicle, sholl be included in 101111 MIWI": i of cxpcndilUre in Ihe ab'ov~ t<lble. 2. 101 ilil schedules if uny expenditure on ~l1()d, Hod services, pJ'Ovidcd by the 1'0lilic(\1 P,lny; or provi<k.d by any p(:rsQnl compallyi frrrn Inssocialionsl /)0<1y or pcrS(lI;S cle. on behall' of Ihe ~andidale, then tlrc' llotionnlllwrkct ",ltI~ ofsuc" goods or services ~re to be int~,'cated, ill rllspcctil'c colul11ns. J. In Pan --1I1, Ihe l.ump-'slim OIHOlinl of fl1nd received [i'oln the politi ca l p,l1'ly 01' others qr Ihc candidate 's OWiI rl1l1d>, should be mentioned dnle \Vis". In all such cases such amollnts ore required 10 lie lirst deposited I" tllr; b~nk accOtin l of the ciulditlntc, opened for ::Iection expenses . 4. Each page ofth~ IIb, tracl SratcI1lC1\' 51)0111(\ be sigllco by Ihe c,lIld idalc

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S. No. INnillc lind ~ddr~ss Dilte

II

- ---f- ...----- - . 4

· I?~ -=_~,,~