1) !I am a candidate set up by Indian National Lok Dal.

2) MMyname is enrolled in 02 - Panchkula, Assembly Haryana, at Serial No 689 in Part No101

3) QMY contact telephone number(s) is 09023597009 and my· e-mail id is"sherwalashok. inld@gmail.com"

railS of PermanentAccount-Number(PAN)andstatusof filing of IncomeTax return.

I, Kusum Bala wife of Ashok Kumar Aged about 43 years, resident of House no.373, stctor 16, Panchk~la, Haryana. a candidate at ·the above election, do hereby solemnlyaffirm gnd state on.oath as under:

PART-A

Affidavit to be filed by the candidate alongwith nomination paper before thereturning officer for election to Lok Sabha from 01 Ambala (S.C.) constituency

M

"FORM 26

(See rule 4A)

23AA 858864

r-

2

Details of Appeal(s} IApplication(s) for revision Nil(if any) filed against the above order( s)

b) The details of cases where the court has taken Nil

cognizance, section(s) of the Act(s) and descriptionof the offence(s) for which cognizance taken

(6) I have not been convicted of an offence(s) [other than any offence(s) referred to in sub­section (1) or sub-section (2), or cover in sub-section (3), of section 8 of the

ame of the Court, Case No.and date of order Niltaking cognizance:

Jl8oII:ouowingcase(s) islare pending against me in which cognizance has been taken by

1'lS-:WUI1 [other than the cases mentioned in item (i) above:-

Nil

Whether all or any of the proceeding(s) have been Nil

stayed by any Court(s) of competent jurisdiction

f)e)

Court(s) which framed the charge(s)

c) Name of the Court, Case No. and date of order Nil

taking cognizance:

b) Section(s) of the concerned Act(s) and short Nildescription of the offence(s) for which charged

a) Cash/First Information Report No.lNos. together Nilwith complete details of concerned PoliceStationl District/State.

Date(s) on which the charge(S) was/were framed Nil

d)

i) The following case (s) is/are pending against me in which charges have been framed bythe court for an offence punishable with imprisonment for two years or more:-

If the deponent is accused of any such offence(s) he shall furnish the following information: -

5) I am not accused of any offence(s) punishable with imprisonment for two years or morein a pending case(s) in which a charge(s) has/have been framed by the court(s) of

competent jurisdiction.

Sf. '.: Names PAN The financial Total incomeNc. year for which shown in

the last Income- Income-taxtax return has return (in Rs.)been filed

1 KUSUM SHERWAL (Self) APBPS3116B 2012-2013 RS 2,97,939/-

2 ASHOK KUMAR SHERWAL AWGPS5328D 2012-2013 RS 3,19,752/-(Spouse/Husband)

3 VIPUL SHERWAL CECPS3875P 2012-2013 RS 1,91,397/-(Dependent - 1 - Son)

4 NUPUR SHERWAl DEZPS3847P 2012-2013 RS 1,83,658/-(Dependent - 2 - Daughter)

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:

SI Description Self Spouse/Husband Depe- Oepe- Depe-No. (Kusum Bala) (Ashok Kumar, ndent-1- ndent-2- ndent-

Son Daughter 3(Vipul (NupurSherwal Sherwal

i) Cash in hand 45,0001- 18,000/- 15,000/- 5,0001- N.A.ii) Details of deposit ii(a)-FDR Muthoot ij (a) Joint Saving Saving Nil N.A.

in BankAccounts Finance Ltd. Rs. 2 NC No 06701010- Nc No.(FDRs) Term Lacs, No. 1460 0437219 in Axis 10000-Deposits and all Present value Rs. Bank. Panchkula 6162532other types of 2.40 lacs approx. with spouse. Balancedeposits including Balance Nilsaving account), Rs. 2,96,5171-Depositswith ii (b) SavingNC No. ii (b) SavingNCFinancial 0670101-00464406 No. 9140100-Institutions, Non in Axis Bank. 10063500Banking Financial Panchkula in Axis Bank.Companies and Rs. 33,283/- Panchkula Rs.Cooperative 2,10,000/-societies and theamount in each ii (c) SavingNC ii (c) Joint Savingsuch deposit. No. 91401001- NCNo

0034748 in Axis 18520100006611 inBank. Panchkula UCO Bank withRs.2,10,000/- spouse. Balance

Rs. 12301-

3

a) The details of cases, Section(s) of the concerned Nil

Act(s) and description of the offence(s) for which

convicted

b) Name of the Court(s), Case No. and date(s} of Nil

order(s):

c) Punishment imposed Nil

d) Whether any appeal was/has been filed against the Nil

conviction order. If so, details and the present

status of the appeal:

Representation of the People Act, 1951 (43 of 1951)1 and sentenced to imprisonment for

one year or more.

If the deponent is convicted and punished as aforesaid, he shall furnish the following

information: In the following cases, I have been convicted and sentenced to imprisonment by a

court of law:-

4

NilNilNil

ii (g) Savings BankAlc in HDFCAlc No.

04351140019470

Balance NilSavings Bank Alc in

savings bank Alc in

PNB, Panchkula. Alc

No.4075000400004743balance 2548/-

ii (f) Joint Saving -

AlC No 62030686398in State Bank of

Hyderabad withspouse. Balance Rs.

112/-

ii (e) Joint Saving AlC

No 18520100006611in UCO Bank with

spouse. for balancesee next column ii (c)

iii) Details of

investment inBonds debentures

I shares and unitsin companies/mutual funds and

others and the Iamount I

~i~v)~~D~e~t-a~ils-o~f~----~~~k-~~--~~~~--~L~IC~~P~O~li-CY-+~N~il-----~----~N-.A-.~

investment in NSS. (Policy No.

Postal Saving. 20693707 (Amount

Ins ranee policies RS.30,000/-)

N.A.Nil

in State Bank of

Hyderabad with

Spouse. ( for detailssee ii (f) of previouscolumn)

00437219 in Axis

Bank. Panchkula

with spouse ( fordetails see next

column)

ii(d) Joint Saving

ii (d) Joint Saving AlC AlC No

No. 0670101- 62030686398

5

73,000/- 92,0001· N.A9,00,747/-

2,90,0001-

Rs. Value

ix) Gross Total Value 20,75,943/-

A /

8,70,000/-

viii) Any other assets

such as value ofclaimslinterest

Value

Market

58,000/- 87,0001-

Rs. Rs.

Value

Rs. Marketof

Nil Nil N.A.

ofValue

300 Gms. Market 100 Gms. Market 20 Gms. 30 Gms. N.A.

and value)

details of weight

thing(s) (give

and valuable

vii) Jewellery, bullion

N.A.NilNilNil

Nil

iv(c)- Lie Policy(Policy No.

20737498 amountRs. 25,000/-)

Rs. 30,000/-)

vi(b)- Mitsubishi

Lancer LXD : HR-15

0-0054 Model Feb-

2012 having present

value about

4,50,0001-

2007 having present

value 2,25,0001-

vi (a)- Mahindra

Make registration

number etc.

year of purchase

and amount)

vi) Motor Vehiclesl

Aircrafts/Yachts/Sh Scorpio HR-16 L-

ips (Details of 0036 Model : March

Nil

amount

iv(b)- L1C

(Policy

20401731

Nilv) Personal loansl

advance given to

any person or

entity including firm

com pany. Trust etc

and other

receivables from

debtors and the

amount

N.A.Nil

Policy

No.

and investment in

a:'IY Financial

instruments in Post

office or Insurance

Company and the

amount

6

Khatauni No. i(a)-

186/191, Agricultural

Khasra No. Land Self

1051116, & acquired

Khewat 1 measuring

Khatauni No. 4 Kanal out of

788/808, Khasra 7 Kanal

NO.1161119 18 Marias

& Khewat comprising

/Khatauni No. in Khewat55/56, Khasra No. 153No. 105 II 15 Khatauni No.totaling 3 K 199-202,16 M in Rakba, Khasra No.

Mauja Billa, 16//2(8-0),Hadbast No. 3/1/1 (2-13),

237, Tehsil & 161/9(8-0),

Distt. PKL. 16//3/2(2-13),

4/1(7-8),

I(b)- 50% share 16113/1/2

in Agricultural (2-13), Kitte 6.land measuring2 Kanal inKhewaV

Khatauni No.186/191, Khara

No. 1051116 inRakba, Mauja

B. Details of Immovable Assets:

SI Description Self Spouse Depe- Depe- Depe-No. (Kusum Bala) (Ashok ndent-1 ndent-2 ndent-3

Kumar) (Vipul (NupurSherwal Sherwal

i) Agricultural Land i(a)- Viii-Billa Nil Nil Nil N.A.

Location(s) Survey Tehsil &number(s) Distt. Panchkula

i(b)- Viii-BillaTehsil &

Distt. Panchkula

Area (total i(a) Agricultural Vill-Alipur, Nil Nil N.A.

measurement in acres) Land Self Tehsil

acquired 8arwala

measuring 3 K & Distt.16 M comprising Panchkulain Khewatl

7

N.A.

N.A.

Nil

Nil

Nil

Nil

market value

Approximate current

Nil

construction etc.

development,

land by way of

Any investment on the Nil

N.A.NilNilNilpurchase) at the time of

purchase

Cost of Land (in case of Nil

N.A.NilNilNilNilDate of purchase in

case of self-acquiredproperty

N.A.NilNilNilWhether inherited Nilproperty (Yes or No)

N.A.NilNilNilArea (total Nilmeasurement in sq.ft.)

N.A.NilNilNilii) Non-Agricultural Land: NilLocation(s) Survey

number(s)

N.A.NilRs.6,58,228/- Nil

i (b)

Rs. 11,25,0001-

Rs.42,75,000/-

i (a)market valueApproximate current

N.A.NilNilNilAny investment on the Nil

land by way of

development,

construction etc.

N.A.NilRs.6,58,228/- Nil

i (b)

Rs. 11,25,000/-

purchase) at the\time of Rs. 42,75,000/­purchase.

Cost of Land (in case of i (a)

N.A.NilNili (a) 15.05.2012 21.10.2008i (b) 24.07.2012

Date of purchase incase of self-acquired

property

N.A.NilNilNoNoWhether inherited

property (Yes or No)

Billa, Hadbast

No. 237, Tehsil

& Distt. PKL.

iii) Commercial buildings Nil Allotment of Nil Nil N.A.

. {including apartments) Commercial

-Location(s) Showroom

-Survey number(s) No. 355 in

Shalimar

Mega Mall,

Sector 5,

Panchkula

Area (total Nil 500 sq. ft. Nil Nil N.A.

measurement in sq. ft.)

Built-up Area (total Nil 500 sq. ft. Nil Nil N.A.

measurement in sq. ft.)

Whether inherited Nil No Nil Nil N.A.

property (Yes or No)

'Date of purchase m Nil Allotment in Nil Nil N.A.

case of self-acquired the year16.10.2004

property

Cost of property (in Nil Cost of Nil Nil N.A

case of purchase) at Propertyoffered Rs.

the time of purchase 35,10,000/·paid up tillnow ininstallments26,78,3221-

Any investment on the Nil Nil Nil Nil N.A

property by way of

development,

construction etc.

Approximate current Nil Rs. Nil Nil N.A.

market value26,78,3221-

iv) Residential Buildings Urban Estate Nil Nil Nil N.A

(including apartments) : Panchkula H.No.

-Location(s) 373, Sector 16,

-Survey number(s) Panchkula

Area (total measuring Nil Nil Nil N.A.

measurement in sq. ft.) 2248.84 sq. ft.

Built up area (Total Covered Area Nil Nil Nil N.A.

measurement in sq. ft.) 2681.39 sq. ft.Whether inherited Nil Nil Nil Nil N.A

property (Yes or No)

Date of purchase m 07.11.2002 Nil Nil Nil N.A.

case of self-acquired -~Q_ r»:property

Cost of property (in Rs. 16,00,000/- t-r»: ~Ni~~\Nil N.A.

case of purchase) at Already 81-9~~Constructed ~;, ) ~~'1the time of purchase House ~f~~~\ ~; 11;,) j

r ~FV~IN~8

51 Description Self Spouse/Husband Oepe- Depe- Depe-No. (KusumBala) (Ashok Kumar) ndent-1- ndent-2- ndent-3

Son Daughter(Vipul (NupurSherwal) 5herwal)

i) Loan or dues to Muthoot Nil Nil Nil N.A.Bank/financial Financeinstitution(s) Name of Rs.6,96,974.40

the Bank or financial (Gold Loan)

institution, Amount I

outstanding, Nature of

Loan

Loan or dues to any Nil Nil Nil Nil N.A.Other individuals/entityother than mentionedabove Name(s)Amount outstanding, ,

nature of loan

Any other liability Nil Nil Nil Nil N.A.

Grand total of liabilities Rs.6,96,974.40 Nil Nil Nil N.A.ii) Government dues: Nil Nil Nil Nil N.A.

Dues to departmentsdealing with

government

accommodation

Dues to department Nil Nil Nil Nil N.A.dealing with supply of

water

Dues to department Nil Nil Nil Nil N.A.dealing with supply ofelectrici!Y_ ~n~Dues to department Nil ~~~. <i

~Nil N.A.

dealing with supply of ~.~~ If'I I Itelephones/mobiles iCpJ ~ Ai ;~9!J[-<, I~MW. OJ::7NlJ.\ 9

77

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

government:-

Any investment on the Nil Nil Nil Nil N.A.

hand by way of

development,

construction etc.

Approximate current Rs. 95,00,000/- Nil Nil Nil N.A.

market value

v) Others (such as Nil Nil Nil Nil N.A.

interest in property)

vi) Total of current Rs. RS.33,36,550/- Nil Nil N.A.

market value of (i) to 1,49,00,000/- I

I I(v) above

10

candidate (otherwise write 'Independent')

Name of the political party which set up the Indian National Lok Dal

(01) Ambala (S.C.) Parliament

Constituency, Haryana

2. Full postal address

1.H.No. 373, Sector 16, Panchkula,

Haryana

Number and name of the constituency and state3.

(11) ABSTRACT OF THE DETAILS GIVEN IN (1) TO (10) OF PART- A:

PART-B

Kusum BalaName of the Candidates

(10) My educational qualification is as under:-

1) Master of Arts in Hindi from Osmania University in year 2003.

2) Doctor of Philosophy in Hindi from Kurukshetra University in year 2009.

(b) Spouse - Self Employed

(a) Self - Self Employed

(9) Details of profession or occupation:

Dues to department Nil Nil Nil Nil N.A.

dealing with

government transport

(including aircrafts and

helicopters)

Income tax dues Nil Nil Nil Nil N.A.

Wealth tax dues Nil Nil Nil Nil N.A.

Service tax dues Nil Nil Nil Nil N.A.

Municipal/Property Tax Nil Nil Nil Nil N.A.

dues

Sales Tax dues Nil Nil Nil Nil N.A.

Any other dues Nil Nil Nil Nil N.A.

iii) Grand total of all Nil Nil Nil Nil N.A.

Government dues

iv) Whether any other Nil Nil Nil Nil N.A.

liabilities are in

dispute, if so, mention

the amount involved,

and the authority

before which it is

pending.

8. Details of Assets and Liabilities in Rupees

Description Self Spouse Depe- Depe- Oepe-(Kusum Bala) (Ashok ndent-1 ndent-2 ndent-3

Kumar) (Vipul (NupurSherwal Sherwal

A. Moveable Assets 20,75,943/- 9,00,7471- 73,000/- 92,0001- N.A.(Total value)

B. Immovable Asset 1,49,00,000/- 33,36,5501- Nil Nil N.A.

Purchase Price of 59,87,5001- 33,36,5501- Nil Nil N.A.Sef-acquired

immoveable

property

II Development I Nil Nil Nil Nil N.A.construction cost

of immovableproperty afterpurchase (if

applicable)

III Approximatecurrent market

price of-

11

7. PAN of Year for which Total incomelast Income shownTax return filed

a) Candidate APBPS3116B 2012-13 Rs. 2,97,939/-KusumSherwal

b) Spouse AWGPS5328D 2012-13 Rs. 3,19,7521-Ashok Kumar Sherwat

c) Dependents (i) CECPS3875P 2012-13 Rs. 1,91,3971-VipulSherwal

(ii) DEZPS3847P 2012-13 Rs. 1,83,658/-Nupur Sherwat

i) Total number of pending cases where charges Nilj have been framed by the Court for offences

punishable with imprisonment for two years or

more

ii) Total number of pending cases where the Nilcourt(s) have taken cognizance [other than the

cases mentioned in item (i) above]

6. Total Number of cases in which convicted and Nil

sentenced to imprisonment for one year or more

[except for offences referred to in sub-sections (1),

(2) or (3) of section 8 of Representation of the

People Act, 1951]

12

DEPONENTNOTARY PUBUt, a/}~mba'aC~M

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 there from. I further declare that-

(a) there is no case of conviction or pending case against me other than those mentioned initems 5 and 6 of Part A and B above;

(b) I, my spouse, or my dependents do not have any asset or liability, other than those

mentioned in items 7 and 8 of Part A and items 8, 9 and 10 of Part B above.

VERIFICATION

a) Self acquired 1,69,75,943/- 42,37,2971- 73,0001- 92,0001- N.A.-...~ assets (Total

Value)

b) Inherited assets Nil Nil Nil Nil N.A.

(Total Value)

9. Liabilities

i) Government dues Nil Nil Nil Nil N.A.(Total)

ii) Loans from Bank, Muthoot Nil Nil Nil N.A.

Financial Finance Gold

Institutions and Loan

other (Total) Amounting Rs.

6,96,974.40

10. Liabilities that are

under dispute

i) Government dues Nil Nil Nil Nil N.A.(Total)

ii) Loans from Nil Nil Nil Nil N.A.Bank, Financial

Institutions and

others (Total)

11. Highest educational qualification:

1) Master of Arts in Hindi from Osmania University in year 2003.

2) Doctor of Philosophy in Hindi from Kurukshetra University in year 2009.

1

,..,.".........sum Sherwal W/o Ashok Kumar Sherwal belonging to Harijan (Chamar)

rtificate to the deponent, wherein the name of the deponent was written

2. 9 That subsequently after the marriage of the deponent, the Sub Divisional Officer

a1. . That my maiden name was Kusum Bala. I got married to Ashok Kumar Sherwal

o on 24.6.1988.

panlkula, Haryana do hereby state and affirm as under:-

I, Kusum Bala W/o Shri Ashok Kumar, resident of House No. 373, Sector-16,

Affidavit

23AA 858861

2

ATTESTED

~Deponent

knowledge. No part of it is false and nothing has been concealed therein.

Verified that the contents of my above affidavit mare true and correct to my

Verification :-

Dated:~

Deponent

Place: Panchkula

deponent.

6. That for all intent and purposes Kusum Bala and Kusum Sherwal are the name of

Panchkula belong to the deponent and are true and correct document.

No. MZH4259016 at serial no. 689 in Part NO.101of the Electoral Roll for 02 -

the caste certificate number 1665 dated 9.8.1989 and the Voter Identity Card EPIC

Ambala (SC), Parliamentary constituency and the deponent affirm and declare that

of her nomination for contesting election to the House of People 2014 from the (01)

5. That the deponent has submitted both the documents for verification and in support

Panchkula. The deponent namewas written as Kusum Bala.

4. That in the Voter Identity Card made after shifting to House No.373, Sector-16,

Panchkula.

P.O., Sub Tehsil Ladwa, District Kurukshetra to House No.373, Sector-16,

3.· That subsequently the deponent shifted her residence from Village Sambalkha,