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(See rule 4)

NOMINATION PAPER

Election to the Legislative Assembly of ORISSA STATE

STRIKE OFF PART I OR PARTII BELOW WHICHEVER IS NOT APPLICABLE

PART I

(To be used by candidate set up by recognised political party)

I nominate as a candidate for election to the Legislative Assembly from the....................

... (tfl.(Z(ttt3................=..1:....7..i-...................................,.......Assembryconstiruency.l/^L

candidate s name .... ............ ..J.t.rf.t......./:\.1,.c.!.*.t............

Fathe/s/Moiher,s/lu€ban a'"rr*r*.....,7-A,..r..kr,. .. .*fu.f-*... .......

/ l-His Postat address..- ......t.t.../.!. t.:/..t...........8......4.t..?,*..t;.t..L....1..t. .....(.t.4:.a.\t.E..../t

XcI N.Jn.ta M */rn\

His name is entered at Sr. No, .....,?.5..?..,.,.....,.,.....in Part No . I Y ........of the

I Lo '' , L l"

erectorar ro for .. .. ., ..1....s.|fi.r.K{,i,.....7..\..9..:t..,.... ..........Assembty consrituency :

n o 4/^ a 1->*My name is...........1.?-.(4..!........................

and it is entered at Sl. No. ....4..5..?............in Part No. ....1..4,.....,....,......of the etectorat rott

, !J^ ^?torthe.......r")...hlZt{..!:l^.et.C....t.2....:..1..;..AssemblyConstituency.

o,t. . ..t.>.) ..t.t. LAQ .t l.t'(1:'Subs. by Norifin. No. s. o.55 P(E), dated 9-8-1996).

(Signature ol proposer)

t,

PAHT II

(To be used by candidate NOfset up by recognised political party )

We herebv nominate as candjdate for election to Legislative Assembiytn"........t7f4*2...(g$+ ..EZ ! f .. . .. ..Assembty Constitueicy. ...'

Faihers/rvrotheis/Husband's name.......... S i 16:4 EL 6f ry-n-......'.

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Particulars of the proposers and their signatures

SI,

No.

Electoral Floll No. of proposer

Full name Signature Dat(Part No. of

Electoral Roll

Constituency

Sl. No.

in that

Part

1 2 3 4 5 6

1

2

3

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2N. 8.- There should be ten electors of the Constjtuency as proposers

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PART III

., . l, the candidate mentioned in part t/paltrl ( Strike out which is not appticable ) assent tothis nomination and hereby declare _

(a) rhat t have comp tetea ....--..7t.Art$ l.ar.l .years of ase;4\I STRIKE OUT (b) T, OR (b) Ti, BELoW WHICHEVEF IS NoT APPLICABLE ]

(b) f, that tam ser up at this etectiongJne .....fo^/.^,no..x.oA,onuL..._.......party,which is recognised .- Nati&At eartylSi+e+4y_in r+e Stut" unO tf.,.trn"symbol reserved for the above party be allotted t; me.

(b) 0, that lam set up at this election by th "

........{.nlc.y.r*....,.!o.4*{...........putty, *niis a registered uffeeosfftsed political party/thdt lam contesting this election,an independent candidate, (Strike out which is not applicable) and thatthe symb(I have chosen, ln order of preference are :-

(ii)................ . ................(ii0

(c) that my name and my father s/mother's/husband's name have been correctly spelt

out above in ............. ..O.t/.irr. .................... (Name of thelanguage);

(d) that to the best of my knowledge and belief, I am quaiified and not also disqualifie

for being chosen to fill the seat in the Legislative Assembly of the Slaie.

t lfurther declare that I am a member of t n...........ft.{=&/:.....f .T. k:......--casreltilwhich is a scheduled."eas&/tribe of the State of ............ ilk..e lil&*..................... in retati,

to....7.!14e.4, 4!h...)....(Area) in that State.

I also declare that I have not been, and shall not be, nominated as a candidate at tl

present ** general election/the bye-elections being held simultaneously, to the Legislati

Assembly of...Lr:i!\i4......... (State) from more than two Assembly Consiituencies.

0

Date\ euy't /Thctlk rt

(Signature ot Candidate)

"Score outthe words not applicable

tscore outlhis paragraph, il nol applicable

N. 8. :- A recognised political party means a pol tical party recognised by the Election Commission under I

Election Symbols (Reservalion and Allotment) Order, 1968 rn lhe State concened.

&PART III A

(To be filled by the candidate)

F

N,+ aTbult .

/4v-24(viii)

(ix)

(x)

Was/werp any appeal (s) / revision (s) filed against above conviction (s).........Yes /

Date and pa\iculers of appeal (s)/ application (s) for revision filed

Name of (s) before which the appeal (s) / application (s) for revi:

filed

(xi) Whetherthe said appeal (dVapplication (s)for revision has/ have been disposed (

(xii) lf the said appeal (s) / application (s or revision has / have been disposed of-

(a)

(b)

Date (s) oIdisposa|..................................)

Ptace: N"J^,"ffl-

Date: /). tl 11.56 +i 6 halrra

(Signature of the candidate)

PART IVE

#sn.u^o or nomin"tion paj"t: :' :lfHt ::" ":::'l"n

on'*' '

not appllcable.

PART V

Decision of Returning Officet Accepting u Reiecting the Nonination papet

lhave examined this nomination paper in accordance with Section 36Representation of the People Act, 1951 and decide as follows :-

Date Returning Officer

of the

s&@&&@€eete w I

td

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F) \VI I TO BII

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(3) The follolving cas€(s) is/ are pen'ling agaiDst me in which cognizance has been taken by the court:-

lh;d"tallt.f ."s.. *here lhe coun has laken

cop,nirance. Sections oflhe Act and descrlptrnn

oiitre offence ror wh;ch cognizance taken :

Nffi; the.o"rl."* \""nd Dale of order

taking cognizance :

D;l"l.t Appea l 6; Applit"riont s r for revrto

{ifanylfiled against the above order{s) :

4. Cases in wbich I bave been convicted by a court of law(other those referred to in Form 26):

ff," a.t"* ofc"tes. Sections oflhe

A.i and description of the offence ior

which convicted :

t-/r'Lt l"r" of tGC.,ttftl, Case No. and

Date(s) of order(s) :

FGEhrnent imPosed :

Elli 6)aln^, ,.r*(!, \"

t CfcnDraselfarnelAuN€'TARY PUELIC

llabarangPur

(5) ahat I give hcreiD below lhe delails ofthe ass€ts (m

my spouse and all dependeots:

A. Seiails of movable assets :

r1

(Note:l. Assets in joint name jndicaling the extent ofjoint ownership will also have to be given

2. ln case ofdepositlnvestment, the details including Serial Number' Anount' Date ofDeposit, the Scheme,

Name ofBank/ Institution and Branch are to be given

J. Value of Bonds/share/Debentu res as per the cunent market value in stock Exchange in respecl oflisted

cornpanies and as per books in caseofnon- listed companies should be given'

. Dependent', here means a person, strbslantially dependent on the income oftbe candidate

Details including amount is to be Siven separately in respect ofeach investment)5

J "t".1

or,ny."tr,''J;','l$ti

s.No.

Description Self Spouse Depetrdent-l Depetrdent-2 Depeodeot-3

i) cash in hand Ali\ (\,i \ N\ '\

N\i l

^\-6 1'

(it Details of Deposits in Bankaccounts (FDRS, Term DePosits

and all other q?es ofDePositsincluding saving accounts),

Deposits with FinancialInstiiutions, NonBankingFinancial Companies and

Cooperative societies and theamount in each such deposit

r.-\ i \ t /vr\ /$-r\

iiD Details of investment in Bonds,

Debenturetshares and units incompanies,4\4utual Funds and

others and the amount.

Nrj A,il^,\i,l

N;1 ,t r\

iu) Details of investilrent in NSS,Postal Savings, Insurance Policiesand investm€nt in anY FinancialInst.um€nt in Post office orlnsurance ComPanY and the

N:\ Nr'\- FJ \L N)L A\1L

/)

'i)

iD

l

:)

Personal loans/advance given to

any person or entitY includingfirrn, Company, Trust etc. and

other receivables from debtorsand the amount.

tr\ :\ NrL K\ IL N\ IL \\IL

Molo. Vehicles/Aircraft s/

Yach!s/Ships (details of Make,Registlalion No- etc, Year ofPurchase and amount )

I\\ L NrL N\L ,\\\L N]L

Jewelry, bullion and valuable

thing (give details ofweight and

value) NIL NrL NiL^1

rL N rL-Any other assets such as value ofClaimVinteresl N\L N\\L NrL NIL NIL--Gross Total value

A rl- N\ ]L ,rttL N]L N1l,B, Details oflmmoYable assctsl,t", fl-Frop".lffioint ownership indicating the exrent of joirt ownership will also have to be indicated

2 . Each land or building or apartment should be mentioned separately in this fornat )

'- Bo'li gAndn4,. ., r?,,u'

-Lt

s.\D

s I L'"''tr

R tNFrytTlD#*'.

Spouse Depend€nCl Dependent-2 Dependert-3

r) Asricultural LandLocalion(s)

Suryey rumber(s)r{ ll--- .r,t/ (-- ,r'4u /.1/- y'//r-

Area (Toral measurement inacres) ,/Whether inherited propeny(Yes or NO)

Date ofpurchase in case ofselfacquired property

Cost olLand (in case ofpurchase)at the time ofpurchaseAny Investment orl the land byway ofdevelopment,construction etc. /1 //Approximate Current mark€t

//(iD Non-Asricultural Land

Location(s)Survey number(s) ) /tArea (Total measurement insg. ft.) ,

//

//Whether inherited property(Yes or NO) // //Date ofpurchase in case ofselfacquired property // I /,1Cost ofLand (in case ofpurchase) at the tifte ofpurchase ,' ,/ //Any lnvestment on the land byway ofdeveiopment,construction €tc I //Approximat€ CDrrent marketvalue ,, .//ii) Commercial Buildinqs(including apartments)-Localion(s)-Survey numbe(s)

/

Built up Area (Totalmeasurement in sq. fi_) ./1Whether inherited property(Yes or NO) //Date ofpurchase in case ofselfacquired property

,// //Cost ofproperty (in case oapurchase) at the time ofpurchaseAny lnvestment on thepropefty by way ofdevelopmenf. construction etc.

I,/t

B uh' Bhal,zzt

rffii:*j#H

ftffia'Er/-o,t,;,/rt ,roxrmate Currenl mark\?: f,*7i- /,/ / t- t./r t- '{r- A./,/ t

(iv) Besidenlial Buildinss (includingapaftme'iis,)-Location(s)- Survev numberrs)

tl //

Area (Totai measurement insq. lt.) //Built up Area (Totalmeasurement in sq, ft.) tl !

/t,//

Wh€ther inherited property(Yes or NO) , /lDate of purchase in case ofself

Cost ofproperty (in case ofpurchase) at the time ofpurchase // ,Any lnvestment on the land byway ofdevelopment,construction etc. , ,)/

Approximale Current market, //

(v) Others (such as interest inpropertY) // //

(Yi) Iotal ofCurrenf MarketValue of (i) to (y) aboye

(6) I give hercin below tbe details ofriabilities/ dues to public financial instilutions aDd government :-(Note: Please give separate details of name ofBank, institution, entity or individual-and amount for each item)

s.No,

Description Self Spouse(s) Depend€nt-l Dependent-2 Depend€nt-3

(D Loan or dues lo BanldFinanciallnstitution(s)Name of Bank or FIAmount outstandingNatureofloan

//t L- A/t,- t/tt- /y'tt- t/tt,

Loan or dues lo anyindividuals/ Entity other thanmention€d in (i) above,Name(s)Amount outstandingNatLrre of loan

//

Any other liabilityI r 4

Grand total of liabilities

(iD Government Dues:Dues to departments dealingwith govemmentaccommodation

1)

Dues 10 departments dealingwith supply ofwater , /1

,.a-, r? f

Kcbart}t S€SdtRCtYNOTARY PUBLIC

Nabarrnoour

6/lr' Ehatn q

^// t

Dues to departmerls dealingwith supply oftelephones/mobiles

Dues to departments dealingwith govemmenttransPort(including aircrafts and

helicoDtersIncome Tax D es

Wealth Tai( Dues

service Tax Dues

Municipal /Property Tax Dues

Sales Tax Dues

Any other dues

Grand total ofall Govt. du€s

lfabara ngpui f, .!es to depa(ments dealing\!rrh supply of clectricitY t/rr ,r// r

(7) Details of profession or occupation:a. SelL......... .. . .

b. Spous€.... . --...(8) My educational qualification is as under:

Give details of highest School / University edutation with full fom ofthe certificale/ diploma/ degree course)

Name ofthe Sch;l /College/ University and the year in which the colrrse was compleled )

(9). ABSTRACT OF THE DETAILS GIVEN IN (1) TO (8) ABOVE:

-Name

oithe candidate Sh./smt./Kum. _ A/ _2. Fullpostaladdress

3. iii ber and Name ofthe constituency and

state

3. Narne ofthe Political party which set up th€

candidate (otherwise ur e lll!!p!!!!lll4. @-Numb"t of.ut". in *hich conviction order

Dassed (othertlan those refened to in Form 26)

[l totul number ofn"nding cases where the

court (s) have taken cognizance

5. PAN oT Year for which lastlncome Tax Retum filed

Total Income Shown

fa) Candidate

{b) Spouse:(c Dependents

6. Details ofAssets and Liabilities in rupees

l)escriotion Self Spouse DeDendent-l Dependent-ll DeDendent-lll

MoveableAsset (Total value) /,,4 < r, // c- ^,1r

B. Immovable .//

Btrli thu/rZ ct

!tri \'

ftffiyti#

Purchase PI ice and

Deveiopmenl Cosi ofImmovable Properly

p//t-otalValue

ffioxrmure C,,'rentMarket Price ofAsset (Total Value

Liabilities

'/u -(i) Govemment

dues (Total

G Loans from Bank,

Financial lnstit!tions an

others (Total

Hfrl"st ea,r.ation"t qualificatio0:

{cive details ofSchool/ University education with ftrll form ofthe certificate/ diploma'/ degtee

ourse) (Name of the School /College/ u n'#'ity una tn" y"ur in which the course was compleied )

if'l;?'dffi

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\.ERIFICATION

,.iI:"*n"n,,uoou" nu,"...:,l^XylYlll,lll,l;:H""'j,iljT;:::::l;::T:il:'i'#l'::l[J;?:ii:il:il:i'"h"st ofmv knowledge and belief' no part o

T:'ili,tJi]"" .rr. "r.onviclion or Pending cd5e againcr me other'than tho'e mentioned in items I and 4 abo\ e:

1b; l. m1 spou'e. or m1 dependent' oo not h"ii'"'"i "itt' "t il'u'rrt'j other lhan tnose menlioned in ilems 5 and 6

above-

v*ifiedat....|.r':l::7 il1 tt'i' *'" '" ll: . auv or" " "

gal Alzq/'raDEPONENT

' i.l:lijlg r'r r' rtl:' lr'

2.Affid"vil shoulobes*on' ot' o* un 6''n t'ot -i" ';on"' o Vagis;rateolthe l-ir'l Cld>sor oeforeINoL"r)

Public'I AllcolLmns rhould be filled up and no column to be len blank lfthrrei'noinformotiontolurni'hlnrespe'tof

"". irem. either "\il o' i'lor uppr'cuui": u' rtre case may be shoLld be menlicned

o t r,. ,?iii,tli .rt""'a ue either ryped oi"rinen legibl) and nearl)

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,"oAotaionO .t,.t ' '' detler.$l YJho

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