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2J/ F 'n/ a/.Tbnh;n V. SARAswArHl

FORM 26(See Rule 4A)

Affidavit to be filed by the candidate along withnomination paper before the returning officer for

L,ce,tccd StthP.U''wL-No. 1l- I r{t/ 201l,i-1.No.21-ll'OE/2017

' :ithi ilao,r7, Huiter Ro'd'

" r.rrMKdNDA ' 506 001'

c<ll: 93957 35131

I election to Member of Legislative Assemblvn From : Warangal West-105 Constituencyo

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s r, Rahimunissa, ouo.shuffi#n, ni"o, 37 years, Resident ofE House No.2-1-951, Naimnegar, Ha.nurn[oriOu t:ty and Mandal, WarangalI YLb,_T,_?]:trict,

candidate it tne above etection, do hereby ,or"rnifyI arftrm/state on oath as under:

; 1.I am an Independent candidate." 2.My name is enrolled _ in Warangal West_105, Warangal District,Telangana (Name of the Constituency and the State) at Seriit No.gS9 i;_ Part No.201.

E :. My contact telephone number(s) is 9gg5506 744 and my e_mail ID_ is-trsrahimunissjbegum@gmail_eeE, ind my sociat meJia';;";r;tt")fl (i) trsrahim unissabegum-Face Book

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4. Details of Permanent Account Number (pAN) status of filing of incometax return:

5. Pending Criminal cases

(i)I declare that there is no pending criminal case againstap}ieabl,e) (oR)(ii) The following criminal cases are pending against me: No*(ii) The following criminal cases are pending against me: I

meQr/Not

.1rl;*^\t -.--

(a ) FIR No. with name and address of policestation concerned

(t)2o3/2012of RPS Kazipet

(b) Case No. with name of the Court (L)CC427 /2OL4with Spl, Courtfor ElectedRepresentativesPolitical atHyderabad

Section (s) of the concerned Acts/Codesinvolved, eg., Section.... Of IpC, etc.)

( 1)sec.1a9 (A)& 147 ofRailway Act, .

(d) Brief description of the offence ( 1)Rail Roko .

(e) Whether Charges have been framedmentioned Yes or no

(f) If answer against (e) above is YES. then givethe date on which cha es were framed

( 1)Notapplicable

(s ) Whether any a ppeal/a pplicationhas been filed against the

for revisio np roceed ings

mention Yes or No

(1) No,

6. Cases of Conviction.

(i) I declare that I have not been convicted for any criminal offen '(x)(oR)

(i i)I have been convicted for the offences mentioned betow: N"t- -fl"1r cJ A--f the candidate has been convicted, then tick this alternative and scoreIT

6.n0H{!u Hurr Ptrslc

ADVOC} ::-r lL" t IrY

foI S.B. V{Ait l"GAf

Rogn. tiJT.S

@s&

sI.No

Names Permanent Accountnumber(PAN)

The financial yearfor which the lastIncome tax returnhas been filed

Total incomeshown inincome Taxreturn (Inrupees)

1 AZCPR2865F Nil Nil2 Spouse Nit Nit

Iternative (i) above, and give details in the Table below.

\Lln

SelfNil

(c)

(1) No .

a Case No.b of t eh uCo rt

NitSection ofA Codes involved Nitd( ) Brief DescripEconvicted

on of offence for which Nil

e Dates fo o rd rs fo n ct on NitPun hs me tn m osed Nil(s) a n a eaY p eeb np fi dea a nst ncog ct no rdo re m ne tio n( es

fo oN

NiI

h( ) Ans re to a ob e( esna d nrese t sta ut s of a

Nit

(6A). I have given fult and uptodate information to my politicalparty_ about att.pending -..i-iri"i-""...-;;;;;;"-. and about ailcases of conviction as given in paragraphslsl-

"i(c^arrdidate to whom this.item is. not appricar,. Jj:.'"X" il:j*-Nor AppLTcABLE rN vrEw_ oF,E-NiRr;5'ii,:ii; ilio .1i1, above)(7) That I give herein below the aetaits oi ti.i lrr"t, (movable andimmovable etc. ) of myself, my spouse and all dependents:A. Details of movabte assets:

}::"ij"ffi:Jil,l?:t name indrcatins the extent or joint ownership wi,Note: 2. In case of deoosit/investment, the details including SerialNumber, Amount, date , of O.p"rit, ih"

""r.i!rnu, Name of the

Pa nk/Institution and Branch are to te g,.r"n

- v!'|r!"rNote: 3. Value of Bonds/Share Debent-ures as per current market value inStock exchanqe in resDecr or ristea ionipi;;; ;;;

";'o"r books in case ofnon-listed companies should be glve; "'""'vJ u' ru os I

Note: 4. Dependent means parents, son(s), daughter(s), of the candidateor spouse and any other person related to lhe .."naiaii" whether by broodor marriage, who have not separate ;;;il;';;"me and who aredependent on the candidate for their liveli;;;;: "' "''l:.,;',i".o,*X,li.inctudins

amount is to Ue-liven separatety in respecr of

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B€gn.No.11s{t

sI.NO.

Description Self Spouse Dependant-I

Dependant-2

Oependant-3etc.,

( r.) Cash in hand Rs.1,50,000/- Nit Nil N.Aii)

unts

Details ofdeposit inBa nk

Nit Nil Nit Nil N.A

TE!

$l {t

NitName

Whether has

ise) YES, details

ADVOCATE+ICTA.F'

T.S.ll

Nit

(FDRs, TermDeposits andall othertypes ofdepositsincludingsavingaccounts),Deposits withFina ncia I

Institutions,Non-BankingFinancialCompaniesandCooperativesocieties andthe. amou nt ineach suchdeposit

III Details ofinvestment inBonds,debentures/sharesand units incompanies/Mutual fundsand othersand theamount

Nit Nit N.A

IV Deta ils ofinvestment inNSS, PostalSaving,I nsu ra ncepolicies andinvestment inanyFinancia I

instru mentsinPost office orInsu ra nceCompany andthe amount

Nit Nit Nil Nil N.A

N

Persona I

loa ns/advancegiven to anyperson orentity

Nil Nil Nit Nil N.A

6.Il6Hlll llill ?tlsAD

ADVO'-ATT" O1ARY

For S.R. WAP.,'.NGAL

869n.N0.1190545T.S. [{LB

@5h

1

1V &1

Nil Nil

includingfirm,company,Trust etc.,andotherreceivablesfromdebtors andthe amount

VI

VII

MotorVehicles/Aircrafts/Yachts/Sh ips(Details ofMake,registrationnumber etc.year ofpurchase and

Jewellery.bullion andvaluablething(s) (givedetails ofweight andvalue)

1)TVS Scooty(2010) value ofRs.10,000/-

Nit Nil Nil N.A

Nit Nit Nil Nit N.A

VIII NiI Nil Nil Nil N.A

IX Gross TotalValue

1,60,000/- Nit Nit Nit N.A

B. Details of Immovable Assets:Note: l..Properties in joint ownership indicating the extent of jointownership will also have to be indicaiedNote: 2. Each land or building or apartment should be mentionedseparately in this format

6{) ADVO

!l.t Lltl tllsi!Aft.NOTABY

h(!Rs4.11'

1.S.

SI.NO.

Description Self Spouse Dependant-INit

Dependant-2Nit

Dependant-3etc.,

Nil(i)

NAgriculturalland Location(s), Surveynumber(s)

Nil Nil Nit Nit N.A

\+*' (total Nit Nit Nil Nil N.A

tt

amount)

Any otherassets suchas value ofclaims/interest

r s/ar

measurementin acres)

Whetherinheritedproperty (Yesor No)

Nit NiI Nil Nit N.A

Date ofpurchase incase of self-acquiredproperty

Nit Nit Nil Nit N.A

Nit Nit Nit Nit N.A

Anyinvestmenton theland by wayofdevelopmentconstructionetc.

Nit Nil Nil Nit N.A

Nit Nit Nit Nit N.A

ii) Nil Nit Nit Nit N.A

Nil Nil Nit Nit N.A

Whetherinheritedproperty(Yes or No)

Nit Nit Nil Nit N.A

il uired

Date ofpurchase incase of self-

Nit Nit Nit Nit N.A

1,6 n

I Cost of Lana(in case ofpurchase) atthe time ofpurchase

Approximatecu rrentmarket valueNon-AgriculturalLand:Location(s)Surveynumber(s)

Area (totalMeasurement in sq.ft.)

propertyCost of Land(in case ofpurchase) atthe time ofpurchase

Nil Nil Nit Nit N.A

Anyinvestmenton theland by wayofdevelopmentconstructionetc.

Nit Nit Nil Nit N.A

Approximatecu rrentmarket value

Nit Nit Nit N.A

iii) CommercialBuildings(includingapartments)-Locations(s)-Surveynum ber(s)

Nit Nit Nit Nil N.A

Area (totalmeasurement in sq.ft

Nit Nit Nit Nil N.A

Built-up Area(totalmeasurement in sq.ft.)

Nil Nil Nit Nit N.A

Whetherinheritedproperty(Yes or No)

Nil Nil Nit N.A

Date ofpurchase incase of self-acquiredproperty

Nit Nil Nit N.A

,\

Cost ofproperty (incase ofpurchase) atthetime ofpurchase

Nil Nit Nit Nit N.A

\ \ l$nv Nil Nil Nil Nit N.A

1I n

Nil

Nit

Nit

investmenton theproperty byway ofdevelopmentConstructionetc.

Approximatecurrentmarket value

Nit Nit Nit Nit N.A

IV ResidentialBui ldings(includingapartments):

Location(s)-Su rveynumbe s

Nil Nit NiI Nit N.A

tinsq.ft.)

Area (totalmeasuremen

Nit Nit Nit Nit N.A

Built-up Area(totalmeasurement in sq.ft. )

Nit Nat Nit N.A

Whetherinheritedproperty(Yes or No)

Nit Nit Nit Nit N.A

Date ofpurchase incase of self-acquiredproperty

Nit Nit Nit Nil Nit

I cost ofI property (incase ofpurchase) atthetime ofpUrchase

Nit Nil Nil Nit N I

N

Nil Nit Nit

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Nit

Anyinvestmenton theproperty byway of

rdevelopment

Nil Nit

constructionetc.Approximatecurrentmarket value

Nil Nit Nil Nil

Others (suchas interestin property)

Nit Nil Nit N.A

VI Total ofcurrentmarketvalue of (i)To (vi) above

1,60,000 Nil Nit Nit N.A

8. I give herein below the detairs of my lia birities/d ues to pubric financrarInstitutions and Government: (Note: please give separate details of nameof Bank, Institution, entity or individual and amount for each item)

SI.NO.

Description Spouse Dependant-I

Dependant-2

Dependant-3etc.,

(i) NiI Nil Nit Nit NA

Loan or duesto anyindividual/entity otherthanmentioned in(i) abovename(s)amountoutstandingnature ofloan

Nil Nil Nal Nit NA

N Any otherlia bility

Nil Nil Nil NA

\*,\ Grand total of Nil Nil Nil Nil NA

relsl

N,A

Nit

Self

Loan or duesto Bank/FinancialInstitution(s)Name ofBank orFinancialInstitutions,Amountoutstandingnature ofloan

Nit

lia bilitles

of accommodauonprovided by theGovernment ar anytime dunnq the tast tenyears before the dateof notification of th€current election? ( )

(8)lr ans{er (a) .bov€ rsYES, th€ tolbwhode.laEflon b;

(9nE---zddE!3_--of- -t,lc-

B.lo!.r€drr ,!.e.m*eada.- XlaEoar].

Has rh Deponenthas been tipa

ii) Governmentof liabilitiesDues todepartmentdealing with9overnmentaccommodation

(li) lh€re ls no duesPayable in.esp€ct or above

accommod.tbn totyards

(b)€l€ctrjcity.tarq€{ j@ water Chi.g.. and(d)terephone cha.qer .s onl2.ll-2018.

Nit NA

( iii) Dues todepartmentdealing withGovernmenttransport(including aircrafts andh eli rs

Nil Nit Nit Nit NA

(iv) Income Taxdues

Nit Nil Nit Nit NA

Self Spouse Dependent-1

Dependent-2

Dependent-3

GST Oues Nit Nit Nit NA(vi) MunicipalProperty Taxdues

Nit Nit Nit Nit

(vii) Any otherdues

Nit Nit Nit Nit NA

viii) Grand Totalof all Govt.Dues

Nil NiI Nil Nil NA

ix) Whether anyotherliabilities arein dispute, ifso, mentionthe amountnvolved and

Nit Nit Nit Nil NA

6.n6flltA lHl?tasA0AOVOCA'rEI{orAi\Y

For S.B VIARANGAL

Bogn. No. 1 15:,ts5T,S. lti0iA

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Nit

Nit

NA

&.elat

the authoritybefore whichit is pendinq

I(9) Detaits of(a) Self :

professionSocial wo

or occupation:rker

(b) Spouse : pvt. Driver

9(A) Details of source(s) of Income:(a)Self : Nit(b)Spouse: Salary(c) Source of income, if any, of dependants

:i?r::i::'"t with appropriate Government and anv pubric company or

(a) details of contracts entered by the candidate .,Nit,,(b)details of contracts entered inlo Oy ilouse;[;;;"(c) detaits of contracts entered into bi ;;;;;;uni. "rvil"(d)detaits of contracts ellered into uv ii'iau'u-noii,ioeu ramity or trustin which the candidate or spouie o. O"p"naint, have interest"Nit"(e) details of contracts entered into by partnership firms in whichcandidate or spouse or dependants are par[ners..wit,,(f) Detaits of contracts entered--itit-o ii ;il;6il"nies in whichcandidate or spouse or dependants traveihale ..wit,,

(10) My educational qualification are as under:_

.(Give details of highest School/University education mentioning the fullform of the cerUficate/diotoma/de.g.re" ;;;;;-;;.e of the Schoot/College/University and the year in wliich tht;";;!e ;;; compteted.)

€"9a

6. DU

vocA o-llFor ir )Begn

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Lb,

Name of the Candidate Rahimunissa2 Full Postal Address # 2-1-951, Naimnagar,

Hanamkonda City and Mandal,Waranqal Urban District

J Number and name of theconstituency and State

Warangal West- 105, Telangana

4 Name of the political party whichset up the candidate (otherwisewrite'Independent' )

Independent

5 Total number of pending criminalCASES

( 1 )

6 Total number of cases in whichconvicted

Nil

-7Year for whichlast income Taxreturn filed

Nil

Nit

Total IncomeShown

Nil

Nil

Nil

PART-B

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

B. Details of Assets and Liabilities in RupeesDescription Self Depe

ndantNit

Dependant-2

Nit

Dependant-3etc.,Nil

A) Movable Asset(TotalValue)

Nil Nil Nil NA

B) Immovable Asset Nil Nit Niti)Purchase Price ofSelf acquiredimmovable propertyafter purchase

NitNit

Nit Nil NA

ii) Development/Construction cost ofimmovable propertyafter purchase (ifapplicable)

NilNit

Nil Nil NA

iii) ApproximateCurrent Market priceof

Nil Nil Nil

a) self acquiredassets (total Value)

Nil Nil Nil Nit NA

N b) Inherited Assetstr(total Value)

Nit Nit Nil Nil NA

n

@3

Ro,q{r

1

PAN of

a)Candidate

b NilC) dependants Nil

Nit

enln

Spouse(s)

1,60,000

Nit

Nit NA

6.IAtttou lllll Ptastl)

ADVOO. r i..t!, t1,\iYFoI S.Ft.V:l alA'',.'. -

tl

9 Liabilities Nit Nil Nil Nil NAi) Government dueitotal

Nit Nit Nit Nit NA

ii)fin

Loans from Bank,ancial institution

and others total

Nit Nil Nit Nit NA

10under dis uteLiabilities that are Nil Nit Nit Nil

i) Government duesotal

Nil Nit Nil Nit NA

ii) Loans from Bank,

and others ota I

Financial institutionsNit Nil Nit Nil NA

11

SS c from Govt G rls H h La h5I rka Baza TH na a m nko da a ar n 1 999

VERIFICATIONI, the deponent, above named, do hereby verify and declare that

the contents of this affidavit are true and correct to the best of myknowledge and belief and no part of it is false and nothing material hasbeen concealed therefrom. I further declare that:_(a) there is no case of conviction or pending case against me other thanthose mentioned in items 5 and 6 part A and B above;(b) I, my spouse, or my dependents do not have any asset or liability,other than those mentioned in item 7 and g of part A and items g,9 and10 of Part B above.

Verified at Hanamkonda on thisday of November, 201g

AGEND

ATTESTEIA MAI\JI PNASAI

B Com LLBVOCATE E NOTABY PUBLIC

For S.R. WAFANG \L DIST.TELANGANA, INOIA.

DEPONENT(Rahim unissa)

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