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Affidavit to be furnished by candidate alongwith nomination paper
Before the Returning Officer
for election to _________________________ (name of the House)
from ___________________________ constituency
( name of the constituency )
I, ___________________________, son/daughter/wife of ________________________
aged _____ years, resident of ____________________________________________,
candidate at the above election, do hereby solemnly affirm and state on oath as under:-
(Strike out whichever not applicable)
(1) The following case(s) is/are pending against me in which cognizance has been
taken by the court:-
(i) Section of the Act and description of the offence for which cognizance
taken :
(ii) The Court which has taken cognizance :
(iii) Case No. :
(iv) Date of order of the Court taking cognizance :
(v) Details of appeal(s) / application(s) for revision, etc., if any, filed against
above order taking cognizance :
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(2) That I give hereinbelow the details of the assets (immovable, movable, bank
balance, etc.) of myself, my spouse and dependents*:
A. Details of movable assets.
(Assets in joint name indicating the extent of joint ownership will also have to be given)
S.
No.
Description Self Spouse(s)
Name(s):
Dependent-1
Name:
Dependent-2
Name:
Dependent-3,
etc.
Name:
(i) Cash
(ii) Deposits in
Banks,
Financial
Institutions and
Non-Banking
Financial
Companies
(iii) Bonds,
Debentures and
Shares in
companies
(iv) Other Financial
instruments
NSS, Postal
Savings, LIC,
Policies, etc.
(v) Motor Vehicles
(details of
make, etc.)
(vi) Jewellery
(give details of
weight and
value)
(vii) Other assets,
such as values
of claims /
interests
Note : Value of Bonds / Shares / Debentures as per the latest market value in Stock Exchange in respect
of listed companies and as per books in the case of non listed companies should be given.
*Dependent here means a person substantially dependents on the income of the candidate.
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B. Details of Immovable assets
[Note : Properties in joint ownership indicating the extent of joint ownership will also have to
be indicated]
S.
No.
Description Self Spouse(s)
Name(s):
Dependent-1
Name:
Dependent-2
Name:
Dependent-3,
etc.
Name:
(i) Agricultural Land
- Location(s)
- Survey number(s)
- Extent (Total measurement)
- current market value
(ii) Non-Agricultural Land
- Location(s)
- Survey number(s)
- Extent (Total measurement)
- current market value
(iii) Buildings (commercial and
residential)
- Location(s)
- Survey / door number(s)
- Extent (Total measurement)
- current market value
(iv) Houses / Apartments, etc.
- Location(s)
- Survey / door number(s)
- Extent (Total measurement)
- current market value
(v) Others
(such as interest in property)
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(3) I give hereinbelow the details of my liabilities / overdues to public financial
institutions and government dues :-
[Note : Please give separate details for each item]
S.No. Description Name and address of Bank /
Financial Institution(s) /
Department(s)
Amount outstanding
as on ……………….
(a) (i) Loans from Banks
(ii) Loans from financial
institutions
(iii) Government dues (other than
income tax and wealth tax)
(No Due Certificate to be
enclosed in case holding or
having held any public office)
(b) (i) Income Tax including
surcharge [Also indicate the
assessment year upto which
Income Tax Return filed.
Give also Permanent Account
Number (PAN)]
(ii) Wealth Tax [Also indicate the
assessment year upto which
Wealth Tax return filed.]
(iii) Sales Tax [Only in case of
proprietary business]
(iv) Property Tax
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(4) My educational qualifications are as under :-
(GIVE DETAILS OF SCHOOL AND UNIVERSITY EDUCATION)
(Name of School / University and the year in which the course was completed should
also be given.)
DEPONENT
VERIFICATION
I, the deponent abovenamed, do hereby verify and declare that the contents of this
affidavit are true and correct to the best of my knowledge and belief; no part of it is false
and nothing material has been concealed therefrom.
Verified at ____________ this the _________ day of _______, 200__.
DEPONENT
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