“FORM 4-B

[see rule 26(4) and 27]

Affidavit to be filed by the candidate along with nomination paper and Form 4-A before the Returning Officer for election
……………………………………………….. (Name of the Gram Panchayat/Panchayat Samiti/Zila Parishad, Ward No……………………………..,
Block ………………………………., District ………………………….

I, ………………………………………………….. son/daughter/wife of …………………………………… Aged ……………. Years, resident of

…………………………………. (mention full postal address), a candidate at the above election, do hereby solemnly affirm and state on
oath as under:-

(1) I am a candidate setup by ………………. (Name of the political party)/am contesting as an Independent
candidate.( strike out whichever is not applicable)
(2) My name is enrolled in …………………………………… (Name of the Gram Panchayat/Panchayat Samiti/Zila
Parishad), at Serial No…………………. in Ward No…………………………..
(3) My contact/telephone number(s) is/are ……………………………. and my e-mail id (if any) is …………………………..
(4) That I have not incurred any of the following disqualifications, as laid down under section 175 of the Haryana
Panchayati Raj Act, 1994:-
(a) I have not been convicted and charges have not been framed against me in a criminal case for an
offence punishable with imprisonment for not less than ten years.
(b) I have not failed to pay any arrears of any kind due to me to any Primary Agriculture Co-operative
Society, District Central Co-operative Bank and District Primary Co-operative Agriculture Rural
Development Bank. No dues certificate(s) from the said institution(s) is/are enclosed.
(c) I have not failed to pay arrears of electricity bills. No dues certificate from the concerned Power
Utility is enclosed.
(d) I have passed matriculation examination or its equivalent examination from a recognized
institution/board.

Or

I have passed the middle class.

(In case of a woman candidate or a candidate belonging to Scheduled Caste)
Or
th
I have passed the 5 class.
(In case of a women candidate belonging to Schedule Caste contesting election for the post of
Panch). A true attested copy of certificate issued by the concerned Institution/Board is enclosed.
(e) I have a functional toilet at the place of my residence.

DEPONENT

VERIFICATION

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.

DEPONENT

Note : 1. Affidavit/Declaration should be filed latest by 3.00 PM on the last day of filing nominations.
Note: 2. In case of a candidate seeking to contest the elections of Member Panchayat Samiti and Zila
Parishad, shall have to submit an affidavit sworn before the First Class Magistrate or a Notary Public
or a Commissioner of Oath appointed by the High Court of before the sub-Divisional Officer
(Civil)/Tehsildar/Naib Tehsildar (conferred with the powers of Executive Magistrate) having
jurisdiction to the area.
Note: 3. In case of candidate seeking to contest the election of the seat of Panch and Sarpanch of Gram
Panchayat, shall have to furnish the information on a plain paper.
Note: 4. All columns should be filled up and no column to be left blank. If there is no information to furnish in
respect of any item, either “Nil” of “Not applicable”, as the case may be, should be mentioned.
Note: 5. The Affidavit/Declaration should be either typed or written legibly and neatly.
 “iz:Ik 4&[k
[nsf[k, fu;e 26(4) rFkk 27]

-----------------------------------------------------------(xkzke iapk;r@iapk;r lfefr@ftyk ifj”kn~ dk uke] okMZ la[;k-----------------------

Cykd----------------ftyk-----------------------------------) ds fuokZpu ds fy, fjVfuZax vkfQlj ds le{k mEehnokj }kjk ukekadu
i= vkSj iz:i 4&d lfgr ‘kiFk i= izLrqr fd;k tk;sxkA

eSa----------------------------------------iq=@iq=h@iRuh-------------------------------------vk;q----------------------------o”kZ------------------------------ (iwjk Mkd

irk of.kZr djsa) dk@dh fuoklh gWwa] mijksDr fuokZpu ls mEehnokj gWwa] lR;fu”Bk ls izfrKk djrk gWwa@djrh gWwa] vkSj ‘kiFk
ij fuEufyf[kr dFku djrk gWwa@djrh gWwa%&

(1) eSa--------------------------------(jktuSfrd ny dk uke) }kjk [kM+k fd;k x;k mEehnokj gWwa@Lora= mEehnokj ds
:Ik esa yM+ jgk@jgh gWwaA

(tks ykxw u gks mls dkV nsa)

(2) esjk uke------------------------------(xkze iapk;r@iapk;r lfefr@ftyk ifj”kn~ dk uke)] okMZ la[;k----------esa

dze la[;k--------------------ij gSA
(3) esjk lEidZ@VsyhQksu uEcj-----------------------gS@gSa vkSj esjk bZ&esy vkbZ Mh (;fn dksbZ gks)---------------------gSA
(4) ;g fd eSus gfj;k.kk iapk;rh jkt vf/kfu;e] 1994 dh /kkjk 175 esa ;Fkk vf/kdfFkr ds v/khu
fuEu v;ksX;rk izkIr ugha dh gS%&
(d) eSa fdlh ,sls vijkf/kd ekeys tks nl o”kZ ds dkjkokl ls de n.Muh; ugha gS] esa fl)nks”k
ugha fd;k x;k gWwa vkSj esjs fo:) vkjksi Hkh ugha yxk, gSaA
([k) eSa fdlh izkFkfed d`f”k lgdkjh lkslkbVh] ftyk dsUnzh; lgdkjh cSad rFkk ftyk izkFkfed
lgdkjh d`f”k xzkeh.k fodkl cSad ds mldh vksj fdlh izdkj ds ns; ds fdUgha cdk;ksa dk
Hkqxrku djus esa vlQy ugha jgk gWwaA dfFkr la[;k (laLFkkvksa) ls vkns; izek.k i= layXu gSA
(x) eSa fctyh fcyksa ds cdk;ksa dk Hkqxrku djus esa vlQy ugha jgk gWwa] lEcfU/kr fo|qr mi;ksx
dk vkns; izek.k i= layXu gSA
(?k) eSus fdlh ekU;rk izkIr laLFkk@cksMZ ls eSfVzd ijh{kk ;k blds led{k ijh{kk ikl dh gSA
;k

eSusa feMy d{kk ikl dh gSA

(fdlh efgyk mEehnokj ;k vuqlwfpr tkfr ls lEcfU/kr mEehnokj dh n’kk esa)
;k
eSus ikapoh d{kk ikl dh gSA
(iap ds in ds fy, fuokZpu yM+ jgh vuqlwfpr tkfr ls lEcfU/kr efgyk mEehnokj dh n’kk esa )
lEc) laLFkk@cksMZ }kjk tkjh izek.k i= dh lgh lR;kfir izfr layXu gSA
(M) esjs fuokl LFkku ij dk;Z’khy ‘kkSpky; gSA

vfHklk{kh

lR;kiu

eSa] mij ukfer] vfHklk{kh] blds }kjk ;g lR;kiu vkSj ?kks”k.kk djrk gWwa@djrh gwqWa fd bl ‘kiFk i= dh
fo”k;&oLrq esjh loksZre tkudkjh vkSj fo’okl ds vuqlkj lR; vkSj lgh gS vkSj bldk dksbZ Hkkx feF;k ugha gS vkSj
blesa ls dksbZ rkfRod rF; ugha fNik;k x;k gSA

vfHklk{kh

----------------------------------------------------------------------------------------------------------------------------------------------------------

fVIi.k1%& ‘kiFk i=@?kks”k.kk] ukekadu Hkjus ds vafre fnu dks 3 cts ls igys rd QkbZy fd;k tkuk pkfg,A

fVIi.k2 %& iapk;r lfefr rFkk ftyk ifj”kn~ lnL; ds pquko yM+ jgs mEehnokj ds ekeys esa ] tks izFke Js.kh
eftLVzsV vFkok uksVjh ifCyd vFkok mPp U;k;ky; }kjk fu;qDr ‘kiFk vk;qDr vFkok {ks= dh
vf/kdkfjrk j[kus okys mie.My vf/kdkjh (ukxfjd) @rglhynkj@uk;c rglhynkj (ftls dk;Zdkjh
eftLVzsV dh ‘kfDr;ka iznku dh xbZ gks) ds lEeq[k ‘kiFk&i= ij izLrqr dh tk,xhA

fVIi.k3%& xzke iapk;r ds iap rFkk lajip ds in ds fy, pquko yM+ jgs mEehnokj ds ekeys esa ] ml }kjk
lwpuk lkns dkxt ij rS;kj djds nsuh gksxhA

fVIi.k4%& lHkh dkye Hkjs tkus pkfg,a vkSj dksbZ dkye [kkyh u NksM+sA ;fn fdlh en ds lac/k esa dksbZ
tkudkjh ugha gS rks “‘kwU;” ;k “ykxw ugha gksrk” tSlh Hkh fLFkfr gks] mfYYf[kr fd;k tkuk pkfg,A

fVIi.k 5%& ‘kiFk iFk@?kks”k.kk ;k rks Vafdr ;k lqikB; rFkk lkQ&lkQ fy[kh gksuh pkfg,”A