,

,

•

~.10

MANIPUR

•

FORM 26

(See ru le 4(A)

TEN RUP.EES

RfS.10

01AA

AFFIDAVIT TO BE FILED BY THE CANDIDATE ALONGWITH NOMINATION PAPER , BEFORE THE RETURNING OFFICER FOR ELECTION TO 17'" LOK SHABA ELECTION

I 2019 FROM II OUTER MANIPUR CONSTITUENCY

PARTA I

I, Shri Lorho S. Pfoze, Son of Late A. Sibo Pfoze, aged 59 years, resident of Kayinu Vii ge, P.O. & P.S. Mao, District Senapati, Manipur-795150, a candidate at the above election, do hereby solemnly affirm and state on oath as under:-, (1). I am a ca ndidate set up by Naga People 's Front (N PF).

(2) My name is enrolled in 48-Mao (ST), Manipur, at Serial No. 591 in Part No. 19.

(3~ My contact telephone number(s) is/are 8974634801/8730930933 and my e-mail id (if any) is lorhopfoze@gmaii.com and my social media account(s) (if a ny) is/are.

(i) l Dr. Lorho Pfoze" facebook account.

I

I

I I

I

(4). Details of Permanent Account Number (PAN) and status of filing of Income Tax return:

51. No. Names PAN The financial year for which the last

~\ SION,,", Income-tax Q~ ,v. (j "9! ~ <b return has been ~ -} '6 filed ~ ~I -o ~ f:. ~ ';i~ * ,",,~~ .. ~~

, C/ Self ASLPP20B4L N.A. ~- .. "

2. Spouse AQRPM4140Q N.A.

3. HUF (If the N.A. N.A. Candidate is Karta or Coparcener)

4. Depedent-1 N.A. N.A.

5. Dependent-2 N.A. N.A.

6. Dependent-3 N. A. N.A.

(5). Pending Criminal Cases

(i) I declare that there is no pending criminal case against me.

'--:::':::==7?'5r.Ar~~ -19 (TI(. Jogel Sill{i, ( Oath Commissioner (Jud icial )

Im phaJ West. Manipur

Total income shown in Income-Tax return (in Rupees) for the last five Financial Years (as on the 31st

March] (i) (iil [iii] (iv) (vl (i)

(ii] {iii) [iv] (v) fil [ii] (iii) (ivl (v] (il (ii] (iii) (iv] (v] (il fiil (iiil (iv] (v)

[i] (ii]

(iii) [iv] (v)

a)

b)

c)

d)

e)

t)

g)

OR 0 , ) *

- ",,""' Ldf %J~"",':I1' ~riminal cases are pending against me; ~VES1 , ""

-=;:;:;.. NOT APPLICABLE

TABLE

FIR No. With name and N.A. N,A, address of Police Station concerned Case No. With Name of N,A, N.A. the Court Section(s) of N.A. N.A. concerned Acts/ Code involved (give No. Of the Section .... of fPC, etc.) Brief description of N.A. N.A. offence Whether charges have NO N.A. been framed (mentioned YES or NO) If answer against (e) N.A. N.A. above is YES, then give the date on which charges were framed Whether any NO N.A. Appeal / Application for revision has been filed against the proceedings (Mention Yes or No)'

(6) Case of Conviction

N,A.

N.A.

N.A.

N.A.

N.A.

N.A.

N.A.

(i) I declare that I have not been convicted for any criminal offence.

OR

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

NOT APPLICABLE

•

TABLE

'" , ,

(a) .....:: --- Case No. N. A. N.A. N.A . (b) Name of the N. A. N.A. N.A.

Court (c) Sections of NA N.A, N.A.

Acts/ Codes involved (give No. Of the Section, e.g. Section ... of IPC etc

(d) Brief N.A. N.A. N. A. description of offence for which convicted

(e) Dates of N.A, N.A. N.A. orders of conviction

(I) Punishment N. A. N.A. N.A. imposed

(g) Whether any NO N.A. N.A. Appeal has been med against conviction order (Mention YES of NO)

(h) If answer to N.A. N.A. N.A. (g) above is YES, give details and present status of appeal

(6A) I have given full and up·to-date inform,ation to my political party about all pending criminal 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 NOT APPLICABLE IN VIEW OF ENTRIES IN Sri) and 6(i), above]

Note:

1. Details should be entered clearly and legibly in BOLD letter .

. .:l ( :>' 1'1 (T/( . Jog!!! IIIgh

Oath Commissioner (Judicial) Impha t West , Manipur

2. each case under different columns against

3. reverse chronological order, i.e. the latest case to be mentioned first and backwards in the order 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 of2011.

(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 be given.

Note 2: In case of deposit/Investment, the details including Serial Number, Amount, date of deposit, 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 Exchange in respect of listed companies and as per books in case of non­listed companies should be given.

Note 4: 'Dependent' means parents, sones), daughter(s) of the candidate or spouse and any other person related to the candidate whether by blood or marriage, who have no separate means of income and who are dependent on the candidate for their livelihood.

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

Note: 6. Details should include the interest in or 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 or institution abroad, and details of all assets and liabilities in foreign countries.

~ I,. Jog . sivih 1 :r l'"r

Oath Commissioner (Judicial) Impha l West, M:lnipur

-SI. No. (i)

(ii)

Description

Cash in hand .

Rs. _. 100,000/

Details deposit Bank

of i) . Saving in Account

No. 32712616 accounts

(FDRs, Term 015 Deposits and Outstandi all other ng types of deposits including saving accounts), DepOSits with Financial Institutions, Non-Banking Financial Companies and Cooperative societies and the amount in each such deposit

Balance Rs. 3,146/-ii) . Saving Account No. 07530101 03391 Outstandi ng

Balance Rs. 2,21,558/-

s',--15,00,0 0 / -Saving Account No. 115871 04205 Outstan ding Balance Rs. 2,20,64 Sf-

HUF

N.A.

N.A.

Dependent-l

N.A.

N.A.

(iii) Details of 500,000 N.A. N.A. N.A. investment in Shares @

Bonds, Rs. Debenlures/ S 10=Rs. hares and 50,00,00 units in 0/ -, companies/ M Intouch utual Funds Naturals and others Private and the Limited amount.

(iv) Details of N.A. investment in NSS, Postal Savings, Insurance Policies and investment in any Financial

N.A. N.A. N.A.

( (T/<. JOg,f,l'illi/i --6?>- ''1 Oath Commissi~ner (Judicial)

Imphal West . Manipur

Dependent-2 Dependent-3

N.A. N.A.

N.A. N.A.

N.A. N.A.

N.A. N.A.

1

... in Post Office or Insurance Company and the amount

(v) ioans/advanc e given to any person or entity

- including firm, company, Trust etc. And other receivables from debtors a nd the

(vi) Motor vehicles/ Airc rafts/Yachts/ Sh ips (Details of Make, registration number, etc. Year of purchase and

(vii) I ! . y, bullion and valuable thing(s) (give details of weight and

I (viii) Any V"'«

assets such as value of c1aims/ intere st

(ix) Gross Total value

~<'n~ '~<J/ .... . ~ . .

~ A !JlW' " I" --. . "

N.A.

N.A.

I N.A.

N.A.

Rs. 52,23,70

14/-

I N.A. N.A. N.A.

N.A. N.A. N.A.

N.A. N.A. N.A.

N.A. I N.A. N.A.

Rs. N.A. N.A. 2,35,64

Is/-

c '3 - (,/ I,. Jo . S ~g"

Oath Commissioner (Judicial) Imphal West, Mani pur

N.A. N.A.

N.A. N.A.

N.A. I N.A.

N.A. N.A.

N.A. N.A.

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

Note: 3. Details should include the interest in or ownership of offshore assets.

SI. Description Self No

(i) Agricultural N.A. land Location(s) Survey numberfsl Area (Total N.A. measureme nt in acres) Whether N. A. inherited property

I jye~/No'l Date of N.A. purchase in case of self-acquired

I property Cost of Land N. A. (in case of purchase) at the time of purchase Any N. A. Investment on the land by way of developmen t, constructio n etc. Approximat N.A. e Current market value

Spous HU Dependen e F t-l

N. A. NA NA

N.A. N.A. N. A.

N.A. N.A. N.A.

N.A. N.A. N.A.

N. A. NA N. A.

N.A. N.A. N.A.

N.A. N.A. N. A.

\-C----rii. ~q i) ~ ~ -1'1 (TI,. J()1J Siqg I . .' . . Oath CommISSIoner (JudIcIal )

I mphal West. Manipur

Dependen DependeD t-2 t-3

N.A. N. A.

N.A. N. A.

N.A. NA

N.A. N.A.

NA N. A.

N.A. N.A.

NA N. A.

~.A ' / /P' -, -

(ii) Non­Agricultural land location(s) Surveyed n ,

Area (total measurement in so.ft .1

inherited property

(Yes/No)

Date of purchase in case of self­acquired property

Cost of land (in case of purchase) at the time of

purchase

Any Investment on the land by way of development, construct ion etc.

Approximate current market va lue

N.A.

N.A.

N.A.

N.A.

I N.A.

N.A.

N.A. N.A.

N.A. N.A. N.A.

N. A. N.A. N.A.

N.A. N.A. N,A.

N. A. N,A. N.A.

N.A. N.A. N.A.

N.A. N.A N.A.

' .2. '?> -1 ~ (T/~ . Jil P Sj~I~1t

Oath Commissioner (Judlclnl l Imphal West. Manipur

N.A. N.A.

N.A. N.A.

N.A. N.A.

N.A. N.A.

N.A. N.A,

N.A. N.A.

N.A. N.A.

\SSION0O> O~ '"' "," ~lf2 ~ %

~ 'q ,. " « . -_.ti l O :;';( l>

iii) Commercia l N\ \;' S. ' IlA. ~ifA N.A. N.A. N.A. Bu ildings . ." 0"" ~Q;-

\ 741 .-:~

(including 1;-

apartments) -location(s) -Survey number(s)

Area (Total N.A. N.A. NA N. A. NA N.A. measurement

in sq. ft.)

Build-up Area N.A. NA N.A. N.A. N.A. N.A. (Total measurement

in sq.ft.)

Whether N.A. N.A. N.A. N.A. N.A. NA inherited property

(Yes/No)

Date of N.A. N.A. N.A. N.A. N. A. N.A. purchase in case of se lf-acquired

I property (ost of N.A. N.A. NA N.A. N. A. N.A. property (in

case of purchase) at

the time of purchase

Any N.A. N.A .. N.A. N.A. N.A. NA Investment

on the

property by

way of development, construct ion

etc.

Approximate N.A. N.A. NA N.A. N. A. N.A. current

market va lue

\-- J ~p. "Y

(" .:l-J. 4, ~ -,'/ (T/~. J./J~JI sill!: j

OafhCommissioner Judiciall ( Imphal We st. Manipur

~,\<;SIONto>

O~ '"& (j ~~~ 0

,:t- ~!:~ '0 '"' fi~ -« ,. ~

iv) Residential Kayinu NA~ N.~~~ A. ~;J N.A. N.A. Buildings Village, P.O. ~- , ;:" , i''''

<1, . ~:$$. (including & P.S. Mao, J' ~\

"';"; .:.-apartments): District -location(s) Senapati,

Manipur-

795150

-Survey Un-survey

number(s) homestead

land Area (Total 3 acres N.A. N.A. N.A. N.A. N.A. measurement in sq. ft .) Built up Area 3000 sq.fts N.A. N.A. N.A. N.A. N.A. (Total measurement

in sq . ft.) Whether Yes N.A. N.A. NA N.A. NA inherited property (Yes/No) Date of N.A N.A. N.A. N.A. N.A. N.A. purchase in case of se lf-acquired property Cost of N.A. N.A. N.A. NA N.A. N.A. property (in case of purchase) at the time of purchase

Any Land NA N.A. N.A. N.A. NA Investment developme on the land nt and by way of Constructio

development, n dwelling construction House Rs. etc. 30,00,000/-Approximate Rs. NA NA N.A. N.A. N.A. current 80,00,000/-market value

(v) Others (such Rs . N.A. N.A. NA N.A. NA as interest in 2,50,000/-

_\--. P """ A. A? ( '~9j "<'---.(.9-1,) L- (1 1(. Jog Si~/gh

Oath Commiss i ~nc r (Judie;;)) ) Imnhal w .. <:t ~,. " ,,; ..... _

property) Ivi) Total of

current market va lue of Ii) to Iv) above

Rs. 1,12,50,000

/-

(8) . I give herein below the details of liabilities/ dues to public financial institutions and

government;-

(Note: Please give separate details of name of bank, institution, entity or individual and

amount before each item).

51. Description Self Spouse HUf Dependent- Dependent- Dependent-No. 1 2 3 i). loan or dues to N.A N.A. N.A. N.A. N.A. N.A.

BanklFina ncial Institution's) Name of Bank or Financial Institution, Amount outstanding, Nature of loan

Loan or dues to N.A. N.A. N.A. N.A. N.A. N.A. any other individual/entity other than mentioned above. Namels), Amount outstanding, natu re of loan

Any other N.A. N.A. N.A. N.A. N.A. N.A. liability Grand total of N.A. N.A. N.A. N.A. N.A. N.A. liabilities

ii) Government (A) Has the Deponent been in occupation of YES/ NO IPI. Tick the Dues: accommodation provided by the appropriate Dues to Government at any time during the last alternative) departments ten years before the date of notification of dealing with the current election? NO Government

~. -II :,d'xt":

C7n.:$i# 7';-1 '1 "l Oath Commissione r (Judicial )

Imphal West. Manipur

accommodation (8) If answer to (A) above is YES, the fo llowing declaration may be furnished namely:·

(i ii )

(iv)

(v)

(vi)

(vii ) (viii

)

(ix)

(i) . The address NOT APPLICABLE ofthe Government accommodation:

(ii ) There is no dues payable in respect of

above Government accommodation, towards·

a). Rent; b). Electricity charges; NOT APPLICABLE

Dues department

c) . Water charges; and d). Telephone charges as on ..... (date):

[the date should be the last date of the third month prior to the month in which the election is

notified or any date thereafter].

Note· 'No Dues Certificate' from the agencies concerned in respect of rent electricity charges, water charges and te lephone charges for the

above Government accommodation should be

submitted .

to N.A. N.A. N.A. N.A.

dealing with Government

transport

(including aircrafts and helicopters)

Income Tax N.A. N.A. N.A. N.A. dues

Self Spouse HUF Oepende nt-l

GST dues N.A. N.A. N.A. N.A.

Municipal/Prop N.A. N.A. N.A. N.A.

erty tax dues Any other dues N.A. N.A. N.A. N.A.

Grand total of Not Not Not Not

ali Government applicab applicab applicab applicabl

dues Ie Ie Ie e

Whether any Not Not Not Not

other liabilities applicab applicab applicab applicabl are in dispute, if Ie Ie Ie e so, mention the

\---L- (TI,. J"gj;, .IH,&,-6,- \ 'l

a omnll L r L ' o fh C ss one (Jud Cl .111 Im phn\ West. Mani pur

N.A. N.A.

N.A. N.A.

Oepende Depende nt-2 nt-3

N.A. N.A. N.A. N.A.

N.A. N.A.

Not Not applicabl applicabl

e e Not Not applicabl applicabl e e

f ~ ,

amount

involved and the authority before

which it is pending.

(9) Details of profession or occupat ion:

(a). Self: Self employed

(b). Spouse: Government employee

(9Al Detai ls of sou rce(s) of income:

(a) . Self: Entrepreneurship

(b) Spouse: Salary

(cl Source of income, if any, of dependents: Not applicable.

(98) Contracts with appropriate Government and any public companies

(a ), Detai ls of contracts entered by the candidate: Not applicable

(b) Details of contracts entered into by spouse: Not applicable

(c l Details of contracts entered into by dependents: Not applicable

(d) Details of contracts entered in to by Hindu Undivided Family or trust in which the

candidate or spouse or dependents have interest: Not applicable.

(el Details of contracts, entered into by Partnership Firms in which candidate or spouse or

dependents are partners: Not applicable.

(t) . Details of contract s, entered into by private companies in which candidate or spouse or

dependents have share: 500,000 shares, Intouch Naturals Private limited

(10) My educational qualification is as under:

SI No.

1

2

3

Education Board/University Qualification

High School Leaving Board of Education Certificate (HSLC) Manipur

Pre-University North Eastern Hills University, Meghalaya

Bachelor of Regional Institu te of Medicine, Bachelor Medical Science of Surgery (MSSS) (RIMS), lmphal

Oath CommIssIoner (Judicial) Imphal West. Mani Dm

-h . .:9., ~ ( -6"'>-11

(T/(. J.og.r!f' Silll111

Year

1975

1977

1983

I ' - ~ I _ 1 -

l.

2.

3.

4.

5. 6.

7.

8.

A

B

I

Name of the candidate Shri lorho S. Pfoze. Full Postal Add ress Kayinu Village, P.O. & P.S. Mao, District

Senapati, Manipur-795150

Number and name of the const ituency and 48·Mao (ST), Manipur

State Name of the pol itical party which set up Naga People's front (NPf)

t he candidate (otherwise write

'Independent' )

Total number of pending criminal cases Not applicable Total number of cases in which convicted Not applicable

PAN of Year for Tota l Income Shown which last Income Tax Return filed

(a) Candidate ASLPP2084L Not Not applicable appl icable

(b) Spouse AQRPM4140Q Not Not applicable appl icable

(c) HUf Not applicable Not Not applicable applicable

(d) Dependent Not applicable Not Not applicable applicable

Details of Assets and liabilities (including offshore assets) in Rupees Descripti Sel f on

Movable Rs. Assets 3,24,7 (Tota l 04/. Value) Immovable Assets Purchase N.A. Price of se lf· acquired immovabl e property

Spouse HUf Dependent-1 Oependent-2

Rs.2,20, N.A. N.A. N.A. 648/·

N.A. N.A. N.A. N.A.

A ~

(TI, . Jog_ 'Sillfi'h ( 2> - I "I O , .•

ath Commiss ioner (Judicint! Imphal Wes t Manipur

Dependent-3

N.A.

N

N.A.

_~tl q

\l<ISSION"o> O~ I./.

(j ~~ ~ ,l:- ".~ " .-

'"' Wiii ("> « • ':. ~

II Developm NA~ ~ ' N ~ N.A. N.A. N.A.

ent/constr -=. ,.... '4,"" 'I ~/ --uction

, ~ . -'

cost of "-;.-

immovabl

e property

after purchase (if applicable )

III Approxim ato Current Market Price (a)Solf- N.A. N.A. N.A N.A. N.A. N.A.

acquire d (b) Rs. N.A N.A N.A. N.A. N.A.

Inherite 82,50,

d assets 000/-(Total

value)

9 Liabilitie N.A. N.A. N.A. N.A. N.A. N.A.

5

i Govern N.A. N.A. N.A. N.A. N.A. N.A.

ment

dues (Total)

ii l oans N.A. N.A. N.A. N.A. N.A. N.A.

from

Bank, Financia I Instituti

on and

others (Tota l)

10 Uabilitie N.A. N.A. N.A. N.A. N.A. N.A.

5

i Govern N.A. N.A. N.A. N.A. N.A. N.A.

ment

dues (Total )

ii loans NA N.A. N.A. N.A. N.A. N.A.

from

~ ~ f ~~ (TI,. j;;P, S0;;C -63> - ( 7

-1 Oath Commissioner (Judicii\1!

Imphal West. Manipur

,

?~ ~ Bank,

~ ),;" Financia ~ I r~~" ,

Instituti cns and

others (Tota l)

11 Highest educationa l qualificat ion:

51 No. Education uua '"f i Year

I Q,

1 High School Leaving Board of Secondary 1975 Certificate (HSLC) Education '"

2 Pre-University North Eastern Hills 1977 University, M.oh,l,

3 Bahelor of Medicine, Regiona l Institute of 1983 Bachelor of Surgery Medical Science

VERIFICATION

I, the deponent, above named, do hereby verify and declare that the contents of this

affidavit are true and correct to the best of my knowledge and belief and no part of it is false

and nothing material has been concealed therefrom. I further declare that:-

a). There is no case of conviction or pending case against me other than those mentioned in

items 5 and 6 of Part A and B above;

b). I, my spouse, or my dependents do not have any asset or liabil ity, other than those

mentioned in items 7 and B of Part A and items B, 9 and 10 of Part B above

Verified at Imphal this 21st day of March 2019 .

. lemn,'"Y at1lrfr, before me on •• ~L~ .. ~.~. ~.:21J! '1 .)1 .;.Q:.II.nrtne Coun Prem ises by th('

~~~~~~:. ~d.:i~~'~~~'~.4dU:;.~~~:: rh l" d~c l <lr aE1 t seet~ to undcrst:lIld the

('Onte'llt :; fu lly we ll on thei r be ing read ove r od explained to him/her.

(1'1~ . loge./' S iqif,{ .3>~ 1 ~ Oath Commissioner (J udicial)

Imph al West , Man ipu r

• /Assembly Constituency No and Name : 48-Mao

Sm;I;UIl No find Name : 1-Songsong (A-2)

l'aHlO<'s NIH''''' KoIIo H",IS" Numbe. 10-1 A'I'- 30 SUlI FEMALE

",,"'" """'..IH Nurnbot: 105 Ago. 44 S ... FEMALE

, Fath<>r's NanKl ClaIhnr H" .... ~ tlumb4ll . loti A9" Z2 S.·x FEMALE

Husband's Namo Nt;pulll HP ...... t-lunlll.. 106 .Ag.. e2 S'>l< FEMALE

FatllOl"'s Nam" Nupuni Holt ... Numb41. 106 A9" 3(, S,.~ FEMALE

Fatl1<.Jf's Nan1\> Mat~ Ph .. n .... Hou ... tfumb" , 107 ,11.0" 31\ S"x MALE

Adatfl H'l""e IJumb8' 107 Agr, 5.1 S<'~ MALE

" 1' ~",,'I"'s N"m .. A·.II,hr' H"",., /·/umbw. 107

.; 'l"

24 <:,.,. I'"E'-'A~E

'Jail''' .D'h" ~'!Y.- :l'oz" i"'''''-l~ 1'.1;;

~ ~"Y ~!:.\'A~E

S LDhro l~fll)ll

11) S<,x FEVALt:

1\0" 015 "n 0' 1) 1.2019

Fathof's Namo S.tJo OaIVi 1-ioon.~f 105 A9" 22 SIl~ FEMALE

MoShtJYlO FlIIhoI's Namo N..,:lu'~ H0!i5" Nunlb" , 100 AO" 32 so~ MALE

Fathor's Nanw Adam HoYs" "umber . 107 ~u 45 S\l~ MALE

Ke l'lI F~th'''''s N8"1O II II' I~IIri< I-l0\.0011 l-Iumbto, llY1 "(tv 20 S...... FEINILE

. ; ,

M .. "'gPlo;::" SLorIoo PIo.z"

"" 2tl 0::.-. MAlE

-

l ~"" Hoo.rM 1-1un-bo, 105 -'90- 3G s... FEMALE

" Houle N" ... bfi. 105 Agn 25 ~~ FEMALE

" ~Io.n .. l-iurnbe. 100 ,&.gIl JO s..~ FEM .... tE

Part number : 19

"

OFFICE OF THE SUl3-DI~~~~~~ - DIVISIONAL OFFICER,

SONG

Book No, """ti.""""" Cer< No, ,,'f,~,'t.,,'f- Regn. No. of the Application .-.. ./ .. ::J."" ..

SCHEDULED TRIBE CERTIFICATE

Thi, i, to certify that Shritsmf~.,;"~~dYf..~,,,;P¥,, ,, , , S/o,~fShri/~ ........ d:.~ ... ~ ...... T' .~ .................................................................... Presently resident

ofH/No..!.Q8"c:t.l:;?"""""Vill<lg. I Town """"""""""" """""""""""l!...~""""'"'''''''''''''' in Song Song Sub-Division, Senapati District of the State of Manipur belongs to ....... ~ ................................... ..................... recognized as Scheduled

Tribe as per entry at 51. No ........... J..4. .......... of the relevant constitution order and/or the Act mentioned below:-

He~belongs to .............. ~r.:Y.~ ........................... Religion.

The Constitution (Scheduled Castes) order, 1950 The Constitution (Scheduled Tr ibes) order, 1950 The Constitution (Scheduled Tribes) (Un ion Territories) order, 1950

The Constitution (Scheduled castes) (Union Territories) order, 1951. (as a mended by the Scheduled Castes and Scheduled Tribes list (Modification) order, 1956. The Bombay Re-o rganisation Act, 1960. The Punjab Re­

organisation Act, 1966. The state Himachal Pradesh Act, 1970 and the North Eastern Areas (Re-organ isation) Act, 1971 and the Scheduled Castes and scheduled Tribes order, (Amendment) Act. 1976. The Constitution (Scheduled Tribes order (Amendment) Act. 2011.

2. Shri/Smt/Km .......... ?::fJ.~ ..... ~ .. : ... f!!j~ ............................................... and/or his.lAef"family ordinarily resident in

H/No, I¢ff::::!tz'""", Viliagel'U>wn."_ .......... """.c.~ ... V~"""""" .. ",, ... .in Song Song Sub - Division ofSe napati Distr ict of the State ofManipur of the dare issue of notificabo(of the refe rred order/Act, below: -

The constitution Oammu and Kashmir) Scheduled Castes order, 1980 The constitution (Andaman and Nicobar Island) Scheduled Tribes order, 1959

The constitution (Dadra and Nagar Haveli) Scheduled Castes order, 1962 The constitution (Pondicherry) Scheduled Castes ord er, 1964 The constitution (Utter Pradesh) Scheduled Castes order, 1967

The co nstitution (Gao, Daman Diu) Scheduled Castes order. 1968 The constitution (Nagaiand)'Scheduled Tribes order, 1970 The constitution (Slkklm) Scheduled Castes order, 1978

The constitution (Slkklm) Scheduled Tribes order, 1978 The constitution Scheduled Castes and Scheduled Tribes order, (Amendment) Act, 2002.

The constitution (Scheduled Tribes) Order, (Amendment) Act, 2011.

(Signature of the Certificate Holder).

Dated, Song Song. t,h~/.r..::::","."'!. ,,,=Uf.. , Verified by """S .. ,g,.d,:"""""""""""""",

Indicate the name of Castes /Tribes recognised as Scheduled Castes a nd Tribes

~"

. /, ' \~'tf8.\e . . \I.e ~~ . Q\!;\l'\c\

. ~ec 1 ~e~a~a~ signaturS&~fssumg Authority

Song Song Sub - Division.

Write the name of the Cons titution order and / or the Act under which the Castes/Tribes was notifi ed/ added as Scheduled Castes/Tribes e.g. the Constitution (Scheduled Tribe) order. Note: the tenn ~ordlnarily resides" used here will have the same meaning as In section 20 of the representation ofthe people Act, 1950.

----

NO"' 7.~~.~

-HIGH SCHOOL LEAVING CERTIFICATE

! Y &eh£~L tItat. __ __ fL_ga&~~.-ffJ-h.LPc-. _____ _______ _____ ....

~~ ,I 1 ~~~ ~

5IdI. ____ . ___ . ___ . ___ .J{g.2.tZG'. ___ duLu : ' the 7Afl~ :kkoI '-#/~;r l "''-77'C/

, et:.~. U7- &' 4. 0

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~d and UJ£UJ Piaeed in rthe-~~.- .. - .

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. _ :-,. /1 0 t?:'f.(~r

• IMPHAL

:The--.3.TdH -.l97£ ___ _ ~.

4F.;CRETARY ,

.

" 'I

/ .

,

M. B. B. S. EXAMINATION uUNE 1982

ijJ;lris is to tertif!! tlrat

0164

__ ___ y? 2tY'lk '~~'---__ _ 0/"" ~ ~ Jt.d",a/'if',J'',?'', f~~!%J JfC 178

~ /,,,,,,,,,( ~ Y,;".a/ Jl §&. §&. @? ?5'=u'nat"o,. ,("t'f/

in ~.n.<>nd ~t%&G;"l- -7.9.8£, and kin;? .~~

~ ~ ~ 0/"" tie 'Pt. ........ ,~, k. ?ud~d /0- tk

.§?~~ S§a~ ~ ~e'£"';,,e a.,d ~'?"':Y and ,,~

ImphIJ . 1<~tUr~ 1- 12-1983 Vice-Chancellor

"'-:-'--" r ~'-I' ,,-,. \ ~'~I;';)Cl

OFFICE OF TH E MANAGER ;. 1 !. N ! P ~.; !~ S'I. \ TE Pl)WEH DISTRIBU TI ON COMPANY LTD .

"I AD-TA DIl IlI SUB-DI VISIO N ~ - .. -- .- - - ---------- ----- - ----- - - - -

~ t/) -(p ~{~ ~ :Dr J-or ho Pfove ;;, "'''J' 0 if' '" (

f.J u,A< ,u 1 'J 01- IW, ye-r() v,U) cvn..Jyy Cftn ~ vm'lM' , ~ 1r ""Ja--n no,

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°D p( J....D( ~o Ph! 0'/) {(Ott" 4. v;IJ

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'I ",,'1)-(.£/ ~c.,;,.,~1 j,.. 09>1 "W'hM fDC

( Arfl..Af ",.".<1 C '" "",J '" ."-1'L~ hl() )

an., o--n,ewJ Ib IZ~ q, 6 S ~ ;-

3>v. C-e11 ~ wnvr jYM',f !<.<>

0,0&0 j- v;@..< U(eu""pr ",,0 Ci-l 0S,O Muf IQ/3j, 'i wrw(

~.J ~ ( 1(> '" 0 ~"J ~ t "",-J<') oj J i u.<J """''' 4, It Q->-Orl) ~

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"n.cJ,;"1 1= J:, rAM r 1 <Y} ~ C1j 1.c 'J -- '1..0 { 'j ,

_, No .?::/\'j ELECTRICITY BILL

Maximum Demand

Meter No. i\I1elering Voltage Power Fador

Multiplying Factor

Consumer No.

Name of Consumer

Address in full

:A - ~(, 5

: \>.,., . \.... D"" '" Q

Phone No., Fax. &-mail :

g

D. .. 0\Z-~,,~~ IVISIOn. ..... ........... . . .... . ... ... ..... . .

Connected Load: ....... t ...... 1<YV Contract Demand : .............. KW

Category of Supply ............ ...... 0.

CT Ratio :

~~Oli .. PT Rat.,.

a: . A Energy Charge on ': (i) ............... units @ ... .......... .

:I ~ {ii) .... ........... units @ ............ ..

Rs. Rs. ..................

o crJ0~e~ (iii) ............... units @ ............. .

~ see·" 9\ (IV) ..... ... ....... units ~Ub~T~t~i·(A) ~" . Rs. ..................

. ............. ,,~ . . .................

J= B Fixed I Demand Charges (KW/month or KVNmonth) Rs . .... k." .... ffi C Meter Rent'

ir D Sub-Total (A+B+C)

Rs. . .................

Rs. .f},::\f, 1= E Arrear Due: (a) Current year (from 1 stApril20 ...... ) Rs . .. . 5 .. " .. \ en (b) Previous year (as on 31st March 20 ..... )

C OR

Rs . ..................

I ~ in 0: [

~

. Advance : (a) Amount Rs . ..................

F Sub-Total (O+E)or(D-E) Rs. 'i!>:9.>..I...l.

G (i) Current Surcharge Rs . . ................ .

(Ii) Arrear StJrcharge Rs. . ..... ........... .

Accumulated Surcharge Rs. ...Ob .... H ...

H Total (F+G) Rs. .. ............... . I Rebate of Rs. 0 .05 per unit on units consumed (A) Rs. . ................ .

J Total Payable before due date (H-I) Rs . Q;Z:.58 K Add 2% Surcharge on F Rs. . ...... \ .2....4

L Total Payable after due date (J+K) Rs . .G\.'"1!67

Bill Prepared by :- f / /r

Meter Reader . __ Man~o~ /131 ~ I.I~ ·· ····· ··.-· · ··· ··"'Mla~on

Itif't atlllbl· S U b:oriiii! ion

'6'lOWMSPitl""", I N.o. 11/0 Govummof1t of MDnipurs Contribution is 37.22:

ELECTRICI TY BILL

,

OMStON ................... :!?MEiL ...................... -,,.

ConsumerNo.

Name of Consumer

Address (] full

Meter No.

Date ofBiIl .... !..~!~/(..!. ..... Due Date ................... .

Amount Paid

(i) . Current Bill :

(ii) Arrears :

(a) Current years

(from 1st April , 20 .... J (b) Previous Years

Rs ................ .

Rs ................ .

(as on 31st March, 20 .... J Rs ............... .

Sub-Total (Ii) Rs ................ .

(iii) Surcharge :

(i) Current Surcharge

(ii)Arrear Surcharge

Accumulated Surcharge

Sub - Total (iii)

Total [(I)+(li)+(iii))

Receipt No .............. ..

Received by :-

Rs . ............... .

Rs ..... .... .. ... .

: :··················· 1 Rs .... ............ 1

Date ............. .

.......... ...................... . SubDivision .J ~ 1I"-;oN' -,-0 \ 'I .

II 0 cl...oJ> r. u.,10 <.,.,,1, . <, '" <:-

1 t, t'Kl' . ,.~ ",., ~ "C; \J ;& ",\0: ~ 'SJ'v

I\- ' ~i". s'" 'v ,. ) ~ ,:s.' ot::FJ

I I

Ph - ,;l0 1 °1

~ '\ CASH RECEIPT

• I iii§i'DJ'L 0 2 0 5 3 0 .=:;.;::::"... 51. No. 3M •

:;'<; _ -; _ ~oJ j Dat~ .... ..... :............ Co) 6' (!. 0 (Loy Ml

ReceIved with thanks a sum of Rs .... .. I ................... D •• : •..•. ......

from ShIVSm!. ... -ffl?.ztl.:!1:rr: .. r.&.!.!t:!. .. t!.tr.F.!" ... i'.l9. J.~ __ ._., I bearing COOSUl)ef No .... ,f.), .. ::7 ... ,t§.. :f ....................... .. ' ........... ~

of ......... : ...... ................ .... f.:.L: ... ../. ............. ............. Sub-DiviSion,'\ \'~\\\

for the follovffig details: ? (I) Fixed/Demand Charges Rs .......... :~ •. f.P .. .. (ii) Current Energy Charges Rs .. ....... : .... ............ .

(iii) Current Surcharge Rs ....... . /' ........ .... .

(iv) Arrear Energy Charge RS ..... [ ................ .

(v) Arrear Surcharge Rs .......... .. ............. .

(\Ii) Security Deposit Rs ............. ..... ... ,:. ..

(vii) Service Connection Charge Rs ............ ... ......... ..

(viii) Misc. • : S ...... ... , ............. .. RUP<l!'.( .... &.h.,! ........ :.~.!. ":J."'l,,~.F.. 1m ~r· .. -.... ·

J/ ~ t L .... ~('O "'" " ...... l . .

· ·~;~~~ ,~;~ <ii;;;;;~~· · ·· :F: ··~·~~~~b'~IOf1 .. .............. ~Lz:: ........ . . . ......... ~~!iI"ql,,;'ion

"

I

TEN RUREES

~E~ M 'I.? TH COMMISSIONER, (JUDICIAL) MANIP'{fJ AA 807832 AFFIDAVIT

I I, Shri Lorho S. Pfoze, Son of Late A. Sibo Pfoze, aged 59 years, resident of Kayinu

V~l age, P.O. & p.s. Mao, District Senapati, Manipur-795 150 do hereby solemnly affirm

a~d take on oath as follows: .

I 1. That, I am bona fide citizen of India hailing permanently from the above-

I 2.

I 3. , mentioned address. That, while appearing for my High School Leaving Certifi cate (HSLC)

Examination of 1975, I have entered my name as "S. Lorho Pfozhe"; That, whereas in my Permanent Account Number (PAN) Card bearing No. ASLPP2084L my name has been inadvertently entered as "Lorho Sibo Pfozhe", S/o. "Sibi Pfozhe";

4 . That, during the latest electoral roll my name has been reflected in the name &

~ 5_ ;; j g ~ ;:., I style of Dr. "Lorho S. Pfoze", S/o. Late "A. Sibo Pfoze"; ",: - ~."

~ ~ c- l :; ~3 5 "-" g ~ ~'=- I . ~ . e' ;; : , ::: . ': [.z~N:~;-f '--- ' ;;'3° 1 ~ ~ ~ ,s~;:, ~ g 6. _ a i;\ \.~ -. ~g3 · ';:n2

g'- ~'5g " .

"hli: '~~: I ;:l f:) • : ~ :

fJ~ .~ ..... : ~ . ~ ;;--N-i! ~[~ ~k ~~ ~ 1 ~:)

I •

That, I furthe r state that "5. Lorho Pfozhe", "Lorho Sibo Pfozhe", S/o. "Sibi Pfozhe" and "Dr. Lorho S. Pfoze ", S/ o. La te /fA. Sibo Pfoze" a re one and the

same person except spell ing has been wrongly entered at the relevant time; That, I now desire to retain "Lorho S. Pfoze", S/o. Late "A. Sibo Pfoze" for all

relevant purposes in order to avoid future complication;

Verified that the contents of the foregoing statements in para No. 1 to 6

a re true and correct to the best of my knowledge and belief and nothing material is concealed therein.

~{;('t Oath Commissioner (Judici<ll)

Imph<ll West. Manipur

ponent.

I

I

TEN RUBEES

NV~B~H COM MISSIONER, UUDIClAL) MANIPU 1 AA 807833 AFFIDAVIT

I, Shri Lorho S. Pfoze, Son of Late A. Sibo Pfoze, aged 59 years, resident of Kayinu

Viljpge, P.O. & p.s. Mao, District Senapati, Manipur-795150 do hereby solemnly affirm

ana take on oath as follows:

11. That, I am bona fide citizen of India hailing permanently from the above­mentioned address.

12. That, I am not accused of any offence(s) punishable with imprisonment, for two I years or more and there is no any pending case(s) in which a chargers) has been

framed by the courts of competent jurisdiction;

13·

I

That I have not been convicted of an offence referred to in sub section (1) or sub Section (2), or cover in sub section (3) of Section 8 of the Representation of People's Act, 1951 (43 of 1951) and sentence to imprisonment for one year or

more.

Verified that the contents of the foregoing statements in pa ra No.1 to 3 are true and correct to the best of my knowledge and belief and nothing material is concealed therein.

011--01 -19 ( T/~. Jo sflJIJ I

Oath Commissioner (Judicia l) Imphal West, Manipur

ent.

To

ANNEXURE - 2S (CHAPTER VTII, PARA -S.4.2(q))

PART II FORMA

Communication with regard to Authorised Persons to intimate names of Candidates set up by recognised NATJONAL OR STATE Political party or

REGISTERED UN-RECOGNISED political party.

(See paragraph I3(c) , (d) and (e) oflhe Election Symbols (Reservation and Allotment) Order, 1968.)

I. The Chief Electoral Officer, ... .................. ........ ..... ... .. .. ........ ... . (StatelUnion Territory).

2. The Returning Officer for the Q I.J.T. ( !1. ... M. .A-I'i.I/,U,Il, .. ~R.l:i. ~':1! .N. m R t . Constituency.

.. b' .:')u ~ect: - General Elections to .!J:q.~.~ .t .. P.f: . !H. ~. p.f,P. p. ~LCi!!./;'. .~./}. ~!I:'rJ from ... M..'!:N. t P.~~ .............. ......... ...... .. (SthlefU nion Territory) - Allotment of Symbols - Authorisation of persons to intimate names of candidates.

Sir,

In pursuance of paragraph 13 (c), (d) and (e) of lhe Election Symbols (Reservation and Allotment) Order, 1968, I hereby COJTIJUlUlicale that the following person (s) has!have been authorised by the party, which is National Party!State Party in the State of

N A 4 A- l-A "!~. ~. M A-~~p. !!.~ .. lRegistered Un-recognised Party 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 Name of office held in the District(s)!area (s) constituency! send notice party constituencies III respect of

which he has been authorised, I -. 2 3

1.I\VlAN~130W Nt; J.J"l It / .p~ S/D,ENT ",,!tNIPUP- 5. T/!-T6

2. NA-L,J\ tlofl-C< F f/.(W

3. (/V~". )

4.

5.

6.

7.

S.

9.

10.

I Inserted by Notification No. 56/97/Judl-1II, dated 15.12.1997

2. The specimen signatures of the above mentioned person (5) so authorised are given below:·

1. Specimen signatures of Shri " . . A:./llL.I}f:J.q .a.~ lr!.". !:J.F. ...... 1d. ":lft.! "" .... ""."" .. ,," ".

(i) .~~" ... """" (ii)~~ ... "". (iii) "~~." . ,, 2. Specimen signatures of Shri ........ . ....... ............. ... ..... ............. ............. .. .. . . ..... .

. (") ("') (\) ........... . .................. 11 ....................... ........ .. 111 ......... .... . ................... ..

3. Specimen signatures ofShri .......................................................... .. .... ........ ..

(") (" ') (i) ............................... 11 .................. ", .......... ". Ill ........................ " .... .. ..

/<-0 HIM f\ Place ................... .

Dt lq . V 2> . ~ I't a e .................... . - '. .,

NB.

Yours faithfully,

President/Secretary Name of the Party NA- C ft opl.-£'5 Ff.PNT

® i' -)1-~

~ ... If Ii. t-\o~

(Sea Ih arty)

I. 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 (5) mentioned above. No facsimile signature or signature by means of rubber stamp. etc., of any office bearer shall be accepted.

3. No fonn transmitted by fax shall be accepted.

, I

!

FORMB NOTICE AS TO NAME OF CANDIDATE SET UP BY THE POLITICAL PARTY

[SEE PARAGRAl'HS 13(B), (C) AND (E) Al'I'D 13A OF THE ELECTION SYMBOLS (RESE RVATION AA'D ALLOTMENT) ORDE<R 1968J

To,

The Returning Officer for the QlJ. ! ~ f!:. .... /;Ai!:"! P. ,!.f', .. P. .R. 'Y!: ~.~':' ~ ~ . R,.. '1 .. Consti tuency.

Subject:- Ge~al/ Bye Election to .Hp.U. ?t .. lJ. F.: .. I~ .\"-... F~l' P!::f.., .. .( L.().i<, ... 5. .11.1'..<1:") from Q. ~ . :r~!', .. M. Ito'! .'P. ~& .. pA.'::L.l. ~ ':'.~. '.".~'i ... CtJ. ~] I. ~!!~'1. (Name of the Constituency) in ... H.It'.i.!.I'.':IIl, .. ... ..... .............. ...... ...... : ........ ... ...... ...... ........ . (State! Union Territory) - 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 .. ... Hit. .9. il:. .. ~ .0R. LJ.'~ .... p...fl:.e .i<CL ..................................................... (party) (i) that the person whose particulars are furnished in c.olumns (2) to (4) below is the

approved candidate of the party above nwne, 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 generaU bye election from this constituency:

Name of the Constituency

Name of the approved candidate

Father' s! Mother's! Husband's name of approved candidate

I •

Postal address of approved candidate

Name of the Substitute candidate who will step-in (i) on the approved candidate's nomination being rejected on scrutiny, or · (ii) on his (approved

Father's! Mother's! Husband ' s name of substitute candidate

Postal address of substitute candidate

candidate) withdrawing from the contest if, however, the nomination paper of substitute candidate is accepted on scrutiny as an independent candidate and is still a contesting candidate

r---~1 ---+--~2--~--'3---r--4~-+~~~5~~-+--~6---r--~7---

.'

,

I /

/' *2. The notice in Fonn 'S' given earlier in favour of Shril Smt.! Sushri ...... . k~. ItJ1:<:1 .... s.: . .fP.:<> .. <.~ .. ......... .. ............ . as party' s approved candidate! Shri! Smt.! Sushri .............................. .............................................. as party's substitute candidate is hereby rescinded.

3. It is certified that each of the candidates whose name is mentioned above is a member of this political party and hi s name is dul y borne on the rolls of members of this party.

Place ... r..O'H.l.':4. .A. ....................... .

Date ... 1.1 .:. J?~ .. : ... 2-:O".I."I ........ ... .

* Score off, if not applicable.

~~ LA N At-i(, f3<?"1 NE"' MIt0

Presidet'\t Naga Peoole'S Front

(NarMfa~ra S~~n:;~ ~f the Authorised person of the Party)

l. This must be delivered to the Returning Officer not later than 3 p.m. on the last date for making nominations.

2. Fonn must be signed in ink by the office bearer (s) mentioned above. No facsimile signature or signature by means of rubber stamp, etc., of any office bearer be accepted.

3. No form transmitted by fax shall be accepted.

4. Para 2 of the Fonn must be scored off, if not applicable, or .must be properly filled, if applicable.

•

FORM 2A (See rule 4)

NOMINATION PAPER flection to the house of the people

STRIKE OFF PART I OR PART II BELOW WHICHEVER IS NOT APPLICABLE PART I

(To be used by candidate set up by recognized political party)

I nominate as a candidate for election to the House of the People from the ........ .:II ..... 0.11.. r '!.. & .. .... 11 (tN 1. P..IJ.I?. .. .l1J.N. !.711irlil/la(;jfm e nta ry constitue ncy . (andidate's name .. .... ......... i"Q1fHo. .. f,f'.f.Q.k .F ............... .. .. ........... ... ......... ............ . Fath;;,fmother's/husband's name ..... CL::) ... I/::., ... 9'.I.8!l .. .. P.£O .. c..€. ....... ..... ..... .. ... . His postal address .... .. /<;.A."JI.t:l.t!.. .. VI.I",L,:llqF ........................ ... .... ..... ....... ............... .... . His name is entered at S.NO ... ,,~ .. ~ ........ in Part NO ........ .!.'} ............ of the electoral roll for.1.g.-::.Jf1.ft.O ~J~bIY constituency comprised within) 1L/) ... ~pa~-;;:fn~ Constituency.

My name is .... r31/{)()!f. .. KltMFL. ................ ... ..... . and it is entered at S.No ..... C,.tt.5 ........ in Part No .. ... .. X ....... .. ... of the electoral roll for .5't: ... :: ... N.I/.N.q~fI ... (J:.T). *(ASSembly constituency comprised within) ... [[ ... . od.J.Jr.

A1~t.Jt: .......... pariiamentary constituency.

Date .. c?,.r.:::.O.:?.~ . .r')lN 9 Signature of Proposer

PART II (To be used by candidate NOT set up by recognized political party)

We hereby nominate as candidate for election to the House of the People from the ............................ IY. .. , ..... ~ .. ~ .... .... Parliamentary Constituency.

Candidate's name ............................................ ~ .. ~ .... ~ .... : ................................................................. .. Father' s/mother' s/husband' s name ............... . !Y .. ~ .. ..... ':: .... : ......... .. ...... ....... ..................... ............. . "" ,Ij, His postal address ................................................................................................. ............................... ..

1

N,l) IV.-!T. His name is entered at S.No ....... ............. .in Part No ................................ of the electoral roll for

............. ... ........ :N ... ) ... <t. .... .' .............................. .... reAssembly constituency comprised within)

........................ /y. .. ! .... ~ .. .. .. ... .... ... Parliamentary constituency.

We declare that we are electors of the above Parliamentary Constituency and our names are entered in the electoral roll for that Parliamentary Constituency as ind icated

below and we append our signatures below in token of subscribing to this nomination:-

Particulars of the proposers and their signatures

51. Name of Elector Roll No. of Full Name Signature Date no. component Proposer

Assembly Part No. of S.No. in Constituency Electoral that part

Roll

1 2 3 4 5 6 7 1. V 2. 0 /" 3. ~ • 4. NJ 5. Y f ~r ' 6.

/ NO"

7. / 8.

./ V 9. / 10. /' N.B.- There should be ten electors of the Constituency as proposers.

PART III ./

I, the candidate mentioned in Part 1/ ii!-aR II (Strike out which is not applicable) assent

to this nomination and hereby declare -

vfa) that I am a citizen of India and have not acquired the citizenship of any foreign ~

State!Country.

(b) that I have completed ....... .... ~.:; .. ... ................ years of age;

[STRIKE OUT eli) or elii) BE LOW WHICHEVER IS N'pT APPLICABLE] ) . h h· I . b h /lfCUA f~ ,_0 · '4 iF: _J.-I'/IIi'f' (c) (I) t at I am set up at t IS e ectlon y t e .. ... ... .. , ..... ..... ~ ....... r..0:":f?~ ... \..;.

party, which is a recognised National Party/State Party in this State and that

the symbol reserved for the above party be allotted t o me.

OR

2

(c) (ii) that I am up at this election by the ... IY~.'!! ..... ~.~ ... [~:fl.}JI;;) party, which is a registered-unrecognised political party/tR !i~ I elm GQRtestiRg

t-Ri!i 'i1'i'ZtiQR OI~ .m inQepeReeFit etlAeiidate. (Strike out which is not applicable)

and that the symbols I have chosen, in order of preference, are :-

(i) .......................................... ... ...... ..... ......... ... . .

(ii) .

(iii) . ........................................ ..... .......... .. .... ........ .... ........... .

(d) that my name and my father's/mother's/husband's name have been correctly

spelt out above in ......... ~ .. k9 .......... .. .... .. (name of the language);

(e) that to the best of my knowledge and belief, I am qualified and not also

disqualified for being chosen to fill the seat in the House of the People.

* 1 further declare that I am a member of the ..... .......... . ~~ ........................... ..... **caste/tribe

which is a scheduled **caste/trt'be of the State of .... .... ~&.~~ .. f .. ~.~ ................... in relation

to .. ..... ........................................ .. ..... ...... ................................................................ (area) in the State.

I also declare that I have not been, and shall not be nominated as a candidate at the

present general election/the bye-elections being held simultaneously, to the House of the

People from more than two Parliamentary Constituencies.

Signatur of Candidate

YScore Out the words "assembly constituency comprised within" in the case of jammu and

Kashmir, Andaman and Nicobar Islands, Chandigarh, Dadra and Nagar Haveli, Daman and

Diu and Lakshadweep.

*Score out this paragraph, if not applicable.

**Score out the words not applicable.

N.B.-A "recognised political party" means a political party recognised by the Election

Commission under the Election Symbols (Reservation and Allotment) Order, 1968 in the

State concerned.

(1) Whether the candidate ­

(i) has been convicted -

PART III A (To be filled by the candidate)

(a) of any offence(s) under sub-section (1); or

(b) for contravention of any law specified in sub-section (2), ~.

of section 8 of the Representation of the People Act, 1951 (43 of 1951); or Yes/No

(ii) has been convicted for any other offence(s) for which he has been

sentenced to imprisonment for two years or more.

3

If the answer is "Yes", the candidate shall furnish the following information:

(i) Case/fi rst information report NO./NOS .................. (:! .~ ..... 1 .... : .......... . (ii) police statiOn(S) .......... ... ...... ... .... ~.: ........ ~ ...... • .................. ....... ........... .

Distr ict (s) ... .... ...... .. ... .. r.:.. .. ~ .... ~ ....... State(s)... ... .. . .. I"J.. ~ ....... ~ ....... : .. ....... .. ........ . (iii) Section(s) of the concerned Act(s) and brief description of t he offence(s) for which

he has been convicted ................................. (;-!. .... : .... ~ ..... : ................................................. .

(iv)Date(s) 01 conviction(s) .... .. .... .................. I:! . .' ...... '.!. ....... : ........ ................................... .. ... . (v) Court(s) which convicted the candidate ............... /Y. .. : ..... 1 ..... : ..................... ... ........ .... . (vi)Punishment(s) imposed [indicate period of imprisonment{s) and/or quantum of

1 ] /v , 1"r

inels] ............................. .... ..... ......................................... ................................................... .

(vii) Oate{s) of release from prison ........................ t'!.. .. ~ ....... IJ. ..... : ............................... .. ...... . (viii)Was/were any appeal{s)/revision{s) filed against above convict ion(s) ....... ~9. ......... .

Yes/~ (ix) Date and particulars of appeal(s)/application(s) for revision fited ........... (:!.~ ... ~ ... .. :

(x) Name of the court(s) before which the appeal(s)/appl ication(s) for revision filed ...... .

...................... J:! .! .. ~ ............ . (xi) Whether the said appeal(s)/application(s) for revision has/have been disposed of

or is/are pending ...... .................... r!. .. ~ ..... ~ ..... : ......... ..... .... ... .......... . (xi i) If t he said appeal(s)/appl ication(s) for revision has/have been disposed of­

N , II . (a) Date(s) of disposaL ..... .. ............ .............. .. ...... .... .... ..... ..... ...... .. ... ...... .... ... .. ... .... .... ..

/V , .A, . (b) Nature of Drder(s) passed ........................................................................................... .. .

(2) Whether the candidate is holding any office of profit under the Government of India or

State Government? .......................... (Yes/tfu)

-I f Yes, details of the office held ....................... fY. .. ~ ... 1 .... : ... ... .... .. V

(3) Whether the cand idate has been Declared insolvent by any Court ? .... ................ (Yes/No)

-I f Yes, has been discharged from insolvency ............... .... .. ..... ~.1... .. 1 .... : ... " ... " ....... ........ ........ . (4)Whether the candidate is under allegiance or adherence to any foreign

v country? ........................................ {Yes/ N0)

-If Yes, give detai ls .......................... !:!. .. ' .... 1: ..... : ...................... .. .......................................... .. . (S)Whether the candidate has been disqualified under section SA of the said Act by an order

,/ of the President? ... .................................... {Yes/No)

4

N , ;f -If Yes, the period fo r which disqualified ........ ........ .. ...... .... ..... ... ..... .... ...... ... .. .... ................. ....... .. .

(6) Whether 't he candidate was dismissed for corrupt ion or for dis loyalty w hile holdi ng offi ce ...---under the Government of India or Government of any State? .. .. ... ...... ... .. ... ............ (Yes/No)

-If Yes, the date of such djsmjssal. .. " .. ... ... .. .... .. ....... ........ &. ... 1 .. ~. ,,: ... " '''''' ..... "" .... "" .. .......... .. ... .

(7)Whether the candidate has any subsisting contract(s) with t he Government either in

individual capacity or by trust or partnership in which the candidate has a share for

:u:~:n::n~~ .. ~~.~~~ .. . ~~.~.~.~.t(y::;zent or for execution of works unde rtaken by that

-If Yes, with which Government and details of subs isting contract (s) ..... .. .. r.Y .. ! .. 1 .. : ............ .

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

Corporation (other than a cooperative society) in the capital of which the Central

Government or State Government has not less than twenty-five percent share? ... .. ..... ..... .

(v{,/NO)

-If Yes, with which Government and the details thereof .4~~ ... 't. .. ~.~ .. ! ~ 1~1:" .t.~~,Cr1)I'b), c,~f.1J /?-Jl."-

(9)Whether the cand idate has been disqualified by the Commission under section l OA of the v

said Act... ..... .. .... .. .... ... (Yes/No)

-If Yes, the date of disqualification. 1\/ :...'1...: ......... .............. ... ...... ......... ...... .... .

Place: .. ~. Signatur 0 Candida te

Date: &'/O?!":':' I">

PART IV (To be f illed by t he Ret urn ing Office r)

Serial No. of nomination paper ..... . J. ... (.9. .~ .~) .... . This nomination was delivered to me at my office at. ... .. !. .~ ~ . ~ .. f~.( h o ur )

on .. . ?-.~ ;.~.':" .~.~J(date) by t he * cand~propose r . (na me of proposer .... ... ... . --= .......... ....... . .. .. .... )

l~ Return i n~ Office r

RETu' t, .u l ~£. r< NO- 2 0 .M.(ST). P.C.

THOUBAL

21-3-;10Iq Date .... ........ .. ........ . /

5

ANNEXURE XV (CHAPTER V, PARA 21.2

FORM OF OATH OR AFFIRMATION [ARTICLE B4(A) OF THE CONSTITUTION OF INDIA]

[To be made by a candidate for election to Parliament]

I .......... ~.HfJ. .. ?.. .,.~ ...... .. having been nominated as a candidate to fill a seat in

the Go""sil of Slales('House of the People) do swear in the name of the God/Solemnly affirm that I

will bear Irue faith and allegiance to the constitution of India as by law eslablished and Ihall wi ll uphold

the sovereignty and integrity of India.

Ignature and arne in block . / letters of the canqi<la~ I

L l-QR.HO ::::, PF~./

Swqrn in the name of God/Sole 'Vnl~t!irmed by Shri/Shrimati .. ~ .... ~.!?!r.k~ ..... ~ . : ... ~.~.3:' .. : .......... .. at.. 'h.. .. *!:~ ... 1}~J .~. 9.,,?:.(fltaJe) at. .... ....... .J.: . .!Il .... (.-.", .. (hour) this the ......... "' .T. ~, .................... . day of ......... (\\,O\~ ., ,," ... 20 . ..1. J .. ! .................................. before me.

l~ Signature of authorised person­

Namel'Designation '!mj.Se!il· NO- \'KOI.JBAL __ _