,9- Iq - NILOK~EP-I III Name of State/Union Territory \0-&014. J.ifl f<.y RNA. c"eneral EL~c..TIOI'J O~ If\\ j)fp EN:l) f ~T.

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1 ABSTRACT STATEMENT OF ELECTON EXPENSES Annexure 5 PART Name of the Candidate Sh.Smt. Km.l2lBN CHA N) OD Number and name of Constituency q NLOK~EP Name of StateUnion Territory J.ifl f<.y RNA V Nature of Election (Please mention whether General c"eneral EL~c..TO'J O~ Election to State Assembly Lok STflTE AS5EPl8LV Sabha Bye election),9 V Date of declaration of result \0&0 V Name and Address of the Election t'awan K'omAR Aqent Ra ~ RflJ5QN V f candidate is set up by a political f\\ j)fp EN:l) f ~T party, Please mention the name of the political party V Whether the party is a recognised political party ~ ~ Date: G~\(V~ Signature of the Candidate Place: N La K\\fR) Name o,lan (HAN~ OD 03

2 PARTl : ABSTRACT OF STATEMENT OF ELECTON EXPENDTURE OF CANDDATE S. No. Particulars Amt. Amt. Amt. Election expenditure ncurred ncurred ncurred Auth. by authorize (3)+()+(5) Candidate d by Pol. authorize Election Party d by agent(in (in Rs.) others, Rs.) (in Rs.) Expenses in public meeting, rally, procession etc.:. a: Expenses in public meeting, rally, 3.t!,6..toJ := ~ijo6oit:j;~ procession etc. (ie: other than the ones with Star Campaigners of the Political party (Enclose as per Schedulei). b : Expenditure in public meeting rally, procession etc. with the Star Campaigner(s) ~ (ie: other than those for general party propaganda) (Enclose as per Schedule2) Campaign materials other than those used in the public meeting, rally, procession etc. mentioned in S.No. above(enclose as per Schedule3) "93"''j; f' ~:l b.f,;:. e.o Campaign, through print and electronic media.g9i%"":; c...;:) including cable network, bulk SMS or internet ~7PV and Social media lenclose as per Schedule) V Expenditure on campaign vehicle(s), used by V V candidate(enclose as per schedule5) Expenses of campaign workers agents.3 2~~.3 '.i ba;l = cc» (Enclose as per Schedule 6).) j' fv c::j f'.j'~. c.;, D Any other campaign expenditure Grand t;<, b7tlfx ~ )< f. ob T' ( b PART ll: ABSTRACT OF SOURCE OF FUNDS RASED BY CANDDATE S No Particulars Amount (in Rs.) 2 3 Amount of own fund used for the election campaign (Enclose as per Schedule 7) Lump sum amount received from the party (ies) in cash or cheque etc. (Enclose as per Schedule 8) Lump sum amount received from any person company firm associations body of ~Pe>'PdP persons etc. as loan, gift or donation etc., (Enclose as per Schedule 9) Lt J C!>C> tsl5xj z, lj'[) ' 0

3 Schedules to 9: Details of Elections Funds and Expenditure of Candidate Schedule Expenses in public meeting, rally, procession etc. (ie: other than those with Star Campaigners of the Political party) S. Nature of Expenditure Amount Source of Expenditure No in Rs. Amt. incurred Amt. Arnt. incurred Auth. by incurred by others Candidate by Polo agent Party with name Vehicles for transporting visitors 2 Erecting Stage, Pandal & Furniture, Fixtures, poles etc. 3 Arches & Barricades etc. Flowers garlands 5 Hiring Loud speakers, Microphone, amplifiers, comparers etc. 6 Posters, hand bills, pamphlets, Banners, Cutouts, hoardings 7 Beverages like tea, Water, cold drink, juice etc. 8 Digital TV boards display, Projector display, tickers boards, 3D display 9 Expenses on celebrities, payment to musicians, other artists remuneration etc. 0 llumination items like serial lights, boards etc. Expenses on transport, Helicopter aircraft vehicles boats etc. charges ( for self, celebrity or any other campaigner other than Star Campaigner) 2 Power consumption generator charges 3 Rent for venue Guards & security charges 5 Boarding & lodging expenses of self, celebrity, party functionary or any other campaigner including Star Campaigner, tj~,(...,!..: ~"'~.:.... ;"""'''';:> ~ 6 Others expenses f,,;?.f#,.,...:::> e~ ~..,'" ~3J~' 3Jt>,~,p err,. ~ ~ t'ttj'..<::;..,...::) 3~~JJ,::::.c 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) 07

4 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 propagangp'in Rs P 2..,r' 3 Schedule3 Details of expenditure on campaign materials, like handbills, pamphlets, posters, hoardings, banners, cutouts, gates & arches, video and audio cassettes, CDs DVDs, Loud speakers, amplifiers, digital TV board display, 3 D 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 l.o u d :S peq ~~'( ".!J'cD 2 Te.ht O~ C, D r~336 J.,l M~ l3~hneo,~&na L!l.l5 ' tiff O~rK~~~t~)"Q(~n &~6' d 7d2t! 7 V lli 3R ;: ycr " Schedule 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 lelectronic 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. (3) +() m EJ)l A ~'}ltl.~paper Ln ()O~ tr7p. ;;) 2 ~m5 Y 000,,P" ( 3 7~ ~7,v V \ 08

5 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 3a 3b 3c i\e.hkje.. 'l~lloo lou~oo~ hboqo l~lt"2,hoo ~ ~k.3 t5 2 Q'( 3 3~3bOO 3,;3 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. agents candidate Party others agent 2 3a 3b 3c Campaign workers honorarium salary etc. 2 Boarding 3 Lodging THt~fCCd d.,sd.8; dl3jo"ji" Schedule 7 g~hceu~~!?~~~~ 6000,ti>PP ~ v ~95&R J. ~...T"') Details of Amount of own fund used for the election campaign S. No. Date Cash DD Cheque no. etc. with Amount in Remarks details of drawee bank Rs. 2 3 ' 5 6 s 2.fJ t ' 3 ' J 09 ~w,

6 Schedule 8 Details of Lump sum amount received from the party (ies) in cash or cheque or DD or by Account Transfer S. Name of the Political Party Date Cash 00 Cheque no. etc. Amount Remarks, if No. with details of drawee in Rs. any bank 2 3 '" 5 6 7' " f 2 l' 3 Schedule 9 Details of Lump sum amount received from any personcompanyfirmassociationsbody donation etc. of persons etc. as loan, gift or S. Name and address Date Cash 00 Cheque Mention Amount Remarks No. no. etc. with whether loan, in Rs. details of gift or drawee bank donation etc nn"~.~ )ma?..\ UlfA ldonoon ~#,~ ldoonoo On LOqh 2 N~R~"\~fR Ll()()OOD ~, 00000!:Oh LO'lh 3.)()J C'HA\.\) lannjlo~ D ldlll0 0 ft)h l OQ\l V:ffW KtmAR r OOO()O _'ll ~ J il"lh ll')qh ~: qoooq 0 ~O,CJVUU: Note:. n Schedule 5: (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 candidatehis relativeagent 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 table. 2. n all schedules if any expenditure on goods and services, provided by the Political Party; or provided by any person company firm associations body of persons etc. on beha f of the candidate, then the notional market value of such goods or services are to be indicated, in respective columns. 3. n Part, the Lumpsum amount of fund received from the political party or others or the candidate's own 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.. Each page of the Abstract Statement should be signed by the candidate. ~~ 0

7 HARYANA Part V Form of Affidavit 35AA Before the Dis tri ct Election Officer J:;..y«;}.}fTko (District, StateUnion Territory) 0 Af f i d a vi t 0 f S'ho Smt. Ms. 0\AN CJlJN ). 0])... W 0, Slo ;Sh,o AJYJ lr.c ~HhtD, ams~,.qjfl.~l.(tfftnj). 0:.> wo, si 0, aged.. 0 years, rlo V:f.Q of?ajs.ono.. do hereby solemnly and sincerely state and declare as under : () That was a contesting candidate at the general electionlbye election to the hosue of the peoplel Legisla t i ve Assemb y 0f J:f AA Yft7Y't 0 from...~:.m.'. lak..:f;f.{ _.,.: ~ ParliamentaryAssembly Constituency, the result of which.' > ~,' ::(~.~s declared on 90200,,:. '; ;:.. ", ",(2) That limy election agent kept a separate and correct \:\cb," : ~.:");~j;coun t 0 fall expenditure incur red au tho r is ed by memy '~:2,c:Y:,~!,~~;'lection agent in connection with the above election V~C<.'

8 between ~~ 0920 to 9020 the date on which was nominated) and the date of declaration of the result thereof, both days inclusive. (3) 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 supporting vouchersbills mentioned in the said account. () That the account of my election expenditure as annexed hereto inclues 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 withheldsuppreseed therfrom(other than the expense on travel of leader)' covered by Explanations and 2 under section 77() of the Representation of the Peiople Act, 95). (5) That the Abstract Statement of Election Expenses annexed as Annexure, to the said account also includes all expenditure incurred or authorised by me, my election agent, the political party which sponsoered me, other associationsbody 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. Solemnly affirmedsworn by.j&!f!(!tfj!!c(.. at Karnal this day of 't20 before me... ~..,... ~:,...!.; ~~ ~.j r,~....." ~,,~ ~\ O'? ~~ ~ " L,..,.... ":~. ~ ~.. '") <&> ~.. c:!., "). t~~j, \ '", \,".'.t r" T0r"'r\ '''t,.. e CzaJNChuk Def30nent J ':: i{~rn.r.'~l ~. '