ANNEXURE-1. AFFIDAVIT TO BE FURNISHED BY CANDIDATE ALONGWITH NOMINATION PAPER Before the Returning Officer

Transcription

1 , 1 rn, " " lo', ;) ':-'T-.~ ".. ANNEXURE-1 AFFIDAVIT TO BE FURNISHED BY CANDIDATE ALONGWITH NOMINATION PAPER Before the Returning Officer r:~ FOR ELECTION TO THE COUNCIL OF STATES, (Name of the House) FROM ORISSA CONSTITUENCY (Name,?f the Constituency) ~ ~. I, SHASHI BHUSAN BEHERA, aged about - 57 years, Sio - Late Madhusudan Behera, resident of At: Nuapatna, PO: ~anguari, PS: Balianta, Dist: Khurda, orissa, candidate at the above election, to hereby solemnly affirm and state on oath as ~mder: ~Strike out whichever not applicable)

2 (1) The following case (s) is! are pending against me in which cognizance has been taken by the court:- NIL (i) Section of the Act and description of the offence for which cognizance taken: (v) Details of appeal (s)! application (s) for revision, etc., if any, filed against above order taking cognizance. (2) That, I give herein below the details of the assets (immovable, movable, bank balance etc.) of spouse, my dependents and myself*;

3 (Assets in joint name indicating the extent of joint ownership will also have to be given) SI. Description Self Spouse(s) Dependent- Dependent- Dep. - 3 No. Name (s) 1 Name 2 Name etc. Name Shashi Bhusan Suprava Satya Sushree Behera Kumari Prakash Bharati Mohanty Behera (Daughter) (son) (i) Cash 50,000/- 50,000/- (ii) Deposits in Nc No Nc No. Nil Nil Banks, Financial Uco Bank, , Jobra Institutions and Govt. Post Office,. Non-Banking Secretariat Rs.25,OOO/- Financial Bhawan, Companies Branch Rs. 17,057/- Nc No , SBI, Cuttack. Rs.13,913/- Term Deposit Rs.50,OOO/- (iii) Bonds, Nil Future Nil Nil Debentures and General Shares in Insurance Rs. Companies 1.501aks (iv) Other financial Nil N.S.S. & Nil Nil instruments, Kissan Bikash NSS, Postal R.D. Deposit Savings, Lie Rs. 25,000/- Policies etc. $BI Fix deposit Rs.6.00 laks (v) Motor Vehicles Ambassador Nil Scooter Nil (details of make, Car OR-02-AB Hoonda etc.) 0939 Activa OR- 02X-5622 (vi) Jewellery (give Nil 200 gm. gold 30 gm. gold details of weight RS.3,60,000/- Rs. and value) appx. 54,000/- appx.

4 (vii) Other assets, 40,0001- Rs. 5,000/- Rs.5,OOO/- Rs. 5,000/- such as values (Telephone, (Mobile (Mobile (Mobile of claims/ Moble, TV. Phone) Phone) Phone) interests. etc.) Note: Value of Bondsl Sharesl 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. A. DETAILS OF IMMOVABLE ASSETS. (Note: Properties in joint ownership indicating the extent of joint ownership will also have to be indicated) SI. Description Self Spouse(s) Dependent- Dependent- Dependent- No. Name (s) 1 Name 2 Name 3 etc. Name Shashi Bhusan Suprava Satya Sushree Behera Kumari Prakash Bharati Mohanty Behera (Daughter) (son) (i) Agricultural land Mouza: Mouza: Emam Nil Nil - Location(s) Ramashyampur, Nagar, Khata Survey Khata No. 18/2, No. 92, Area Number(s)- 18/4, 18/5, 18/8, A.0.08 dec. Extent (Total 18/9, Area Mouza: Pahal, measurement) - AC.7.50 dec. Rs. Khata No. current market 10.00lakh, 264, Area value Mouza: Sarata, AO.04 dec. Khata No. 157, Rs.3.00 Laks Plot No. 1085, Area AO.12 dec. Rs. 25,000/- (ii) Non-Agricultural Homestead Land land - Mouza: Nakhara, Location(s) jointly having Survey share AO.50 dec. Number(s)- Rs lakhs Extent (Total measurement) - current market value (iii) Buildings Nil (commercial and residential - Location (s) Survey/ door numbers (s) Extent (Total

5 measurement) - Current Market Value (iv) Houses/ Nil Apartments, etc - Location (s) - Extent (Total measurement) - Current market value (v) Other (such as Nil interest in property) 3. I give herein below the details of my liabilities! over due to public financial institutionsand Governmentdues: SI. Description Name & Address of Bank! Amount outstanding No. Financial Institution (s) as on... Departments (a) (i) Loans from Banks Nil (ii) Loans from financial Nil institution (iii) Government dues Nil (a) Dues to departments Nil dealing with government accommodation. (b) Dues to departments Nil dealing with supply of water (c) Dues to departments Nil dealing with supply of electricity (d) Dues to departments Nil dealing with telephones (e) Dues to departments Nil dealing with government transport (including aircrafts and helicopters) (f) Other dues, if any Nil SI. Description Name and Address of Bank! Amount outstanding No. Financial Institution (s)/ as on... Departments

6 (b) (i) Income Tax including Nil surcharge [Also indicate the assessment year upto which Income Tax Return filed. Give also Permanent Account Number PAN (ii) Wealth Tax [Also indicate Nil the assessment year upto which Wealth Tax return filed (iii) Sales Tax [Only in case Nil of ro rieta business iv Pro e Tax Nil (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) H.S.C. B.A. Maharatha Vidyapitha, Naharkanta, Khurda, 1970 Revenshaw College, Cuttack, 1975 (1/ v' 1 AM 1 _\ ita.!/' Iv1J1~Aj?t,J-~() DEPONENT 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 no part of it is false and nothing material has been concealed there from. Verified at Bhubaneswar this the 3 rd day of June, 2010.

7 Jfr16~ ORISSA (qg<q'~. BEFORE THE NOTARY PUBLIC ~ AFFIDAVIT 8 I, SHASHI BHUSAN BEHERA, aged about - 57 years, S/o - Late Madhusudan Behera, resident of At: Nuapatna, PO: Banguari, PS: Balianta, Dist: Kburda, Odisha, do hereby solemnly affirm and state on oath as follows: 5, 1) That. I am the deponent of this affidavit. ~ 2) That, my actual date of birth as per H.S.C. Certificate is (Twelve February Nineteen hundred fifty three), hence my actual age is 57 'Ii years. s 3) That, my age in voter list is recorded as 53 till ~ 4) That, the age on voter list may be ignored and age as per HSC Certificate ~ may be taken into account. 5) That, facts stated above are true to the best of my knowledge and belief. 6) That. the affidavit is required to be produce before Returning Officer for i ; necessary action.

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9 (iv) ~(v). (vi)

10 If the deponent is convicted and punished as aforesaid, he shall furnish the following information: (i) Case/First information reports No.lNos - N/A (ii) Courts (s) which punished - N/A (iii) Police Station(s) N/A, District (s) - N/A, State (s) - N/A (iv) Section (s) of the concerned Act (s) and short description of the offence (s) for which the candidate has been charged - N/A (v) Date (s) on which the sentence (s) was/were pronounced - N/A (vii) Whether the sentence (s) has/have been stayed by any court(s) of competent jurisdiction - N/A.', 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 no part of it is false and nothing material has been concealed therein. Verified at Bhubaneswar, this the 3rd day of June, 2010.

11 a ~~ 'No': ~7' (2~Fi"r~ ~'(1:'l01<::':l',1 ORISSA /:'..;j "\' ~ ~; ),. ~c) ~A \;I ~ '01 v II "'I ~ \\ ~,~""",,y' ~:;~ ~r~~;~ J 3-' ~. ( -( :;i ~1 "'0'~.l.. A \\...-' ",:ft 00 1'" ~'(;:. ~f;' I.":'"/f ~."~~,,'// t' ", '\.,. oil.; ~;\:I"\i~>~~_'~~": ~' "~ <IS>;? ~ Before the Ret~:rn,~g.\Of!iger [; FOR ELECTION TO THE COUNCIL OF STATES, FROM ORISSA CONSTITUENCY 8 AFFIDAVIT J, SHASHI BHUSAN BEHERA, aged about - si years, S/o - Late Madhosudan Behera, resident of At: Nuapatna, PO: Banguari, PS: Balianta, Dist: lq1urda, Orissa, do hereby solemnly affirm and declare as follows: 1. ; (~ \~. 2 ;;. ~,. 3. ~,.~. That, I have filed my nomination paper (8) for the above election. That, in connection with my candidature for the above election I I am submitting herewith the information, as asked for by the Returning Officer, Under Section 8 of the Representation of the People, Act.1951 in the prescribed pro forma. That, the information furnished in the enclosed pro forma is true to the best of my knowledge and belief and that nothing material has been concealed there from. Plcfce: Bhubaneswar Date:

12 / prqlprm;;lfor [wrnishlnginformation under Section 8 of the e,p_,i:\ct~.95'1 by every-candidate at an electiqruqjjaillc!m~ntor StaJe.Leglliatu re r:rom. O~5_!L Constituerlcy Name of the Candidate: cc;lifts 11/ AI/t)(}.4-N F-ather/MBtfTer/HId-&l3-aftd's name 0</)rE /'1If-OfIUS U.DftN ~ /JEfZ/J ill any case specified in sub-section (1) of Section 8 of the Representation of the People Act, 1951 f'-fo (ii) in any case specified in sub-section (2) of the said Section 8. and sentenced to imprisonment for not less than six months (iii) in any other case, and sentenced to imprisonment for not less than 2 years (2) If yes. give details (in each case separately) as below Were you a sittin~j member of Parliament or of i:1 State I.egisiature, on the date of sue;l (Jjj ivictiun. (III) Ir 'jcs. (J ive exl1ctdetails of such status as IJ1fJ/MLf\/MLC. (\/) rllturf~ of offc?nce commit1c:d II/lith rjet:'jils cf \ill~ relc;v3/il Act 8nd Sections)

13 ii/ii) P~:::f1()dfor wllich undergone Impr Isonmenl. if <Jl1j (J) \/\Jas any cippeal / application for revisio!l filed against above COllVlction (i) I~eference No. of such appeal/application for revision filed, if any (ii) Date of filing of such apeal / application for revision (iii) Name of the Court before which the appeal / application for I'evision filed VVhether the said appeal/application for revision has been disposed of or IS pending (v) If disposed of (a) Date of disposal (vi) Whether any bail granted during the pendency of appeal/application for revision : fj lel ce U3t(~ 9f{ ()GiffyMti)./J-!\..~()l/~ Qb ~::{()!O )~J,;; hti'!4~a~ f (Signature of candidate)