s'ble A~eMU; puhl()tr_~ H~JJ{ N' D. ' Name of State/Union Territory Name and Address of the Election

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1 ABSTRACT STATEMENT OF ELECTON EXPENSES Annexure 5 PART - Name of the Candidate Sh./Smt.! Km. sara kj..(ltf../ Number and name of Constituency Name of State/Union Territory ~- H~JJ{ puhl()tr_~ V Nature of Election (Pleasemention whether General Election to State Assembly/ Lok Sabha/ Bye- election) V Date of declaration of result 9 - ()- )-ol~ V Name and Address of the Election ~ ALA)DDlr-..} Agent V f candidate is set up by a political party Pleasemention the name of N' D. ' V the political party Whether the party is a recognised Yes/No «rt: political party s'ble A~eMU; Date: 7/ o / Y Place: ' N~'" Sign:!!:ift; Candidata Name.sA F-A T KHF W 0

2 ! PART- : ABSTRACT OF STATEMENT OF ELECTON EXPENDTURE OF CANDDATE S. No. Particulars Amt. Amt. Amt. Election expenditure ncurred ncurred/ ncurred / Auth. by authorize / ()+()+(5) Candidate d by Pol. authorize / Election Party d by agent(in (in Rs.) others Rs.) (in Rs.) ' Expensesin public meeting rally procession etc.:-. a: Expensesin public meeting rally processionetc. (ie: other than the ones with ~'70 S-b '7/0 Star Campaignersof the Political party. (Encloseas per Schedule-l). b : Expenditure in public meeting rally processionetc. with the Star Carnpatqnerts}. (ie: other than those for general party propaganda) (Endose as per Schedule-2) Campaign materials other than those used in the public meeting rally procession etc. mentioned in S.No. above(enciose as per 55S- ~S-6 Schedule-) Campaign through print and electronic media including cable network bulk SMSor internet and Social media (Enclose as per Schedule-) V Expenditure on campaign vehldeis) used by candidate(encioseas per schedule-s)!9 srro oruo V Expensesof campaign workers / agents (Encloseas per Schedule -6) - - V ' Any other campaiqn expenditure ':z. ~ -tr5r Grand f(""'t~ ~'77 'c<:' PART ll: ABSTRACT OF SOURCE OF FUNDS RASED BY CANDDATE S No Particulars Amount (in Rs.) 2 Amount of own fund used for the election campaign l:tooc (Encloseas per Schedule - 7) Lump sum amount received from the party (ies) in cash or cheque etc. - (Encloseas per Schedule -8) Lump sum amount received from any person/ company/ firm/ associations/ body of 7oto 0 persons etc. as loan gift or donation etc. (Encloseas per Schedule -9).q q... 0 o 0

3 v PART-V ~j/lf FORMOF AFFDAVT ~ ~l (~ ; Before the District Election Officer r..~lfr....{l:!.o/-n'!.)..(district Stat~ni~m-rytoryT""""'''''''-v-..-..''''... "~ Affidavit of Shri/Smt/Ms s.f!f.'.fj..t. /.(ijf).n. (S/o W/o. D/o) $.fi.fl ~F.-... KHtfJ/>.J... f- son/wife/daughter of aged 7.. years rio f(e.fj~.(.j..jn:e;..... do hereby solemnly and.sincerely state and declare as under :- ~O T.. V0.'p.Tha~ was a contesting candidate ~t the general e~ction/bye election to the Housel'f'f the People/. _ '\legl~latlve A~sembl of )...~ M.t:.M.b.... from t:: -::-..PCl.lJ.tU...j... :t fah ''/{!'~~A O... Parliamentary/ Assembly constituency e result of which was declared on 'C' ": t. ~\7./i;{.:~.l.. j."...";.t).-./lj. q ~~~;'.:. 2\W:fjNU{t ' Th.at /my election agent. kept a se~arate and. corre~ account of all ~xpenditure incurred /. J nj;;:' \\~"authonsed by me / my election agent n connection With the above election between.'l7:-:-:.q.!.:/lj - t::t Z) "~::::~:."...J..' (the date on which was nominated) and the date of declaration of the result thereof both days inclusive. () That the said account was maintained in the Register furnished by the Returning Officer for the purpose and the said Register itself is annexed hereto with the supporting vouchers/bills mentioned in the said account. ' l () That the account of my election expenditure as annexed hereto includes all items of election expenditure incurred or authorised by me or by my election agent the political party which sponsored me other associations body of persons and other individuals supporting me in connection with the election and nothing has been concealed or withheld/suppressed therefrom (other than the expense on travel of leaders' covered by Explanations and 2 under section 77 () of the Representation of the PeopleAct 95). -~ (5) That the Abstract Statement of Election Expensesannexed as Annexure to the said account also includes all expenditure incurred 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 () to (5) are true to the best of my knowledge and belief that nothing is false and nothing material has been concealed. Deponent ~ 0 ' ' Solemnly affirmed/sworn by at.n..~.h.this day of 20Y before me. (Signature and seal of the Attesting authority i.e. Magistrate of the first Classor Oath Commissionor Notary Public) ; 05

4 Schedules- to 9: Details of Elections Funds and Expenditure of Candidate j Schedule- Expensesin public meeting rally processionetc. (ie: other than those with Star Campaignersof the Political party) S. Nature of Expenditure Amount Sourceof Expenditure No in Rs. Amt. incurred / Amt. Amt. i'.::;p~ Auth by incurred / by others candidate / by Pol. agent Party with name Vehiclesfor transporting visitors s- -b'"t> 2 Erecting Stage Pandal& Furniture Fixtures poles etc. Arches& Barricadesetc. Flowers/ garlands 5 Hiring Loud speakers Microphone amplifiers ~O/~O 0 comparers etc. 6 Posters hand bills pamphlets BannersCut- srr /" outs hoardings 7 Beverageslike tea Water cold drink juice etc. f>-r ut> 8 Digital TV -boards display Projector displav tickers boards D display 9 Expenseson celebrities payment to musicians other artists remuneration etc. 0 llumination items like serial lights boards etc. Expenseson transport Helicopter/ aircraft / vehicles/ boats etc. charges ( for self celebrity or any other campaigner other than Star Campaigner) 2 Powerconsumption/ generator charges Rent for venue Guards& security charges 5 Boarding& lodging expenses of self celebrity party functionary or any other campaigner including Star campaigner 6 Others expenses ~rr S"(7tO ~s~s8 i i Schedule- 2 Expenditure in public meeting rally procession etc. with the Star campaigner(s) as apportioned to candidate (ie: other than those for general party propaganda) V 07

5 S. No Date and Name of the Star Amount of Expenditure on public meeting Remarks if any Venue campaigner(s) & Name of Party rally procession etc. with the Star Campaigner(s) apportioned to the candidate (As. other than for general party propaganda) in Rs »>.> /'" Schedule- JJ P Details of expenditure on campaign materials like handbills pamphlets posters hoardings banners cut-outs gates & arches video and audio cassettes CDs/ DVDs Loud speakers amplifiers digital TV/ board display [)-display etc. for candidate's election campaign ( ie: other than those covered in Schedule- & 2) S. Nature of Expenses Amount Sources of Expenditure Remarks if any No. in Rs. Amt. By Amt. By Pol. Amt. By others candidate Party agent gp~ }yjam.a.. <.;S'O/- Cfol.d.' P~/ los/-! Schedule- s-rc: i Details of expenditure on campaign through print and electronic media including cable network bulk SMS or internet or social media etc. for candidate S. Nature of Name and address Name and address of Amount Sources of Expenditure No medium of media provider agency reporter stringer in Rs. (electronic (print /electronic company or any person to Amt. By Amt. By Amt. By print) and sms voicel cable whom charges candidate/ Pol. others duration TV social media commission etc. paid/ agent Party etc.) payable if any Col. () +() 2 ' > rn Ps- --- / ~ N 'f5'.> ~ r-----:----- L-- f \ 08

6 Schedule -5 Details of expenditure on campaign vehicle (s) and poll expenditure on vehicle(s) for candidate's election campaign S. Regn. No. of Hiring Charges of vehicle No. of amt. Source of Expenditure No Vehicle & Days for incurred/ Type of which auth. in Rs. Rate for Fuel charges Driver's Amt. By Amt. By Pol. Amt. Vehicle used Hiring of (f not charges candidate/ Party By vehicle / covered (f not agent other maintenan under hiring) covered s ce under hiring) 2 a b c til!. 7~-r ~00 s-uo 'S- ~Sl'b (C).~U - -('l-q - 2 H<. ~ v ot+oo Sl"'D S- ->SZ'" r QSo"2- Hl.-2.e~ '.7Q ~~.s=> (S -l.rzre ( ~o.s= Schedule- 6 Details of expenditure on Campaign workers / agents S. Date and Expenses on Campaign workers amt. Sources of Expenditure No Venue incurred/ Nature of Expenses Qty. No. Of workers Amt. By Amt. By Pol. Amt. By auth. n Rs. f''agents candidate/ Party others. agent 2 a b c campaign workers honorarium/ salary etc.»> 2 Boarding.>: V Lodging / Others -: L-... _ -- Schedule- 7 Details of Amount of own fund u~ed for the election campaign S. No. Date cash 00/ Cheque no. etc. with Amount in Remarks details of drawee bank Rs ~o/-'t ' ~ f? oe-o 2 ~ )J ~(O- f- \ 09 _-.._. -

7 Schedule- 8 Detailsof Lump sum amount receivedfrom the party (les) in cash or cheque or DD or by AccountTransfer S. Nameof the political Party Date cash DD/ Cheque no. etc. Amount Remarksif with details of drawee in Rs. any No. bank ~ --- _- - 2 '\/ f r>: / -- ~ < ~"" Schedule- 9 Detailsof Lump sum amount receivedfrom any person/company/firm/associations/bodyof personsetc. as loan Oift or donation etc. S. Nameand address Date Cash DD/ Cheque Mention Amount Remarks no. etc. with whether loan in Rs. No. details of gift or drawee bank donation etc FtROO<H v rt-c». 7-/0- ::: - 5/5"0/- 'rl5hpfjwjj./... 2 f-rrcrof< tftl"7 ~-/o-- (f &OD/r-- SjLAU./)/J/-/-V;ll. -llrly q~f- iikhpvvp fun' VtJ 'i2iif/b_f "':hu» -/0 ly ')_~ l-r: 'T 7~f)O Note:. n Schedule5:- (a) copy of the order containing list of all vehicles for which permit issued by the Returning Officer to be enclosed. (b) f the vehicle is owned by the candidate/his relative/agent are used for election purpose notional cost of hire of all such vehicles except one vehicle if owned and used by the candidate notional cost of fuel and drivers salary for such vehicle shall be included in total amount of expenditure in the above ~b~. ; 2. n all schedulesif any expenditure on goods and services provided by the Political Party; or provided by any person/ company/ firm /associations/ body of persons etc. on behalf of the candidate then the notional market value of such goods or servicesare to be indicated in respectivecolumns.. n Part - the Lump-sum amount of fund received from the political party or others or the candidate'sown funds should be mentioned date wise. n all such cases such amounts are required to be first deposited in the bank account of the candidate opened for election expenses.. Eachpage of the Abstract Statement should be signed by the candidate... 0