AFFIDAVIT Affidavit to be Sled by the Candidate along with Nomination Paper to the Election Officer/Retursing Officer for Election to Office of CHAIRMAN/Chair person . OF Sunabeda Municipality, Sunabeda [Please striize off the ones not applicable to you) I, Sri Basent Kumar Tripathy, aged about 55 years S/O Late Ghanashyam Tripathy, resident of Village: Q:. No. 0/200, BAL township, Sunabeda-2 PO/PS- Sunsbeda Dist Korapat . Pin "0.763002, 2 condidate on do yf solemnly and state on oath : az the above 1 fam & candidace xt up by -INC (indian National Congress} 2. My name js enrolled in voter list in wert No.l4, Sunabeda Municipality at Serial a No. 737 ia Booth Ne 2. My contact Telephone number(s) is -9437233583 and my email idl f any} is-Nil and my wocial media accounts ( if any) is NA. Da Cw ths fer Porpatty .aa) Botatis of Permanent Asownnt Husuhey APAMD ail otatus of Mllnig of lawose ton retard a nenee mau Hl Rewingis ta hi, Ws het te Jani venue Year ca tn ae i Mell Ae it i) wey sue My as ma mT ay Mey ory Spouse Tae ea ) 99,0%,aat Spo Ls a yp 26h an * fe “a id] \eyoayine on db t aan apy oo MMP ia, ya die _ aan pony FP yoo net Ml] pope. TUF (if Candidate la Te " wit * ]Rialcoparceny fw | ark ee MT wi Yat ‘ aT gate MH] tive x Dependent | ahs Wanssc tas,5 yy Wy " Wy my, we my i mp nh 6 Depenalont t.P y\yy ih my) my si wn} pay mT vi M | vy) foe PAN Halder 10 enecition PAN ad Ibe clearly atated a PAN illatted™ (8) Pending ortminat cases 4.1 / f) () Me following criminal cases ure perviding against me: 110 HTP LI (A Pat (if there are pending criminal cases against the candidate, then tick thin alternative and score off alternative (i) above, and give details of all pending canes in the Table below) Tabie FIR No, with name and acierens of] Police Station concerned By a Sempn le Tre poy, a(Case No. with Name of the ul Bection(s) of coneemed a Acin/Corlen involved (pive no of of Mie Ta) | Briel description of atence Tl tt ute ie charges have been framed (mention YES or NO} wh ene ou (| Wanswer anninat (e] above la VES, then give the date on which] 41 charges were framed. Ca nits te | Whether any Appeal fApplication for revision has been filed —ngainst the qe Nit Ms Proceedings (Mention YES or NO} (elCaree of conviction gh\ fy = sect Tdestore itt hove nt teen: convleei any criminal offence. {Tick this alternative, if the candidate has not been convicted and write NOT APPLICABLE against alternative (i) below) OR (Gi) T have been convicted for the offences mentioned below: 4 \0T APPLICA BLE [ifthe candidate has been convicied, then tick this alternative and score off alternative (i) above, and give details in the Table below) ‘Name of the Court ‘Sections of ‘Acts (Codes involved (give no. of the Section, eg,Tescription of offence for which convicted Dates of orders of [- conviction fey ny wa fe) (h) | Wanswer to (gf above is VES, Period of imprisonment awarded and/or quantum of the fine imposed) Punishment imposed {indicate My ‘) Whether any Appeal bas been filed against conviction erder (Mention YES or No} Repeat the above sequence in respect of each separate case of conviction. sive details and pecent status efappeal fry Ay Hay nal a Wi) | Discharged facquitied im the cases) Section of the Act and description of the offence Ali sh The Court Which hed taken cognizance ny Ni Naf 9 Case No Details of Appeal/application for revision etc. if any filed against above order taking cognizance fr) aM Nip Cases(a) is/are pending against me which cognizance has been taken by Court Section Act and Desription of| the offence for whieh. cognizance ahdis of Ap revision ete, i a inst abave onder Ai ni ‘ (7) That I give herein below the details ss 17, iat era hen by ils of the ussets (movable and immovable ete.) of myself, my A. Details of movable assets; Note: 1. Asscts in joint name indicoting the extent of joint ownership will also have to be given. Note: 2. In ease of depositfinvesiment, the details including Serial Number, Amount, date of deposit, the scheme, Name uf Bank/Institution and Branch are to be given. Note: 4 Value of Bonds/Share Debenturesas per the current market value in Stock Exchange in respect of listed companies and as per books in case of non-listed companies should be giver = Note: 4, Dependent’ means parents, sons}, daughter(#} of the candidate or spouse and any other person related to the candidate whether by blood ar marriage, who have no separate jeans of income and who are dependent on the candidate for their Hvellhood. 1g amount is to be given separately in respect of each investment Note: 5. Details inclu 5 should include the interest in er ownership. Note: 6. Det Explanation, For the purpose of this Foris, the expression” Incindes, detalie of all deposits or investments ; i HUF Dependent | Dependent [Dependent Description mI 2 $ faajnon [20,000] MIL nie Ne nit| “af deposit in accounts [FDRS, ‘Term Deposits and all other types of deposits including saving accounts), Deposits with Financial Institutions Post Office (Current Accounts, Nen-Banking Financial Companies and Cooperative societies and the amount in each such SUNABC DR Bem, SCENT Tana aw deposit Ew je aN (iit | Details “of investment in Bonds, Debentures /Shares and units in tet we companics/Mutual Funds [Yr JM) { Met r and others and the amount. [ier] Betas ot tmvesiment NSS, Postal Saving, Insurance Policies and | 4) | yyy | th) investment in any Financial | +s | ya ray instruments in Post office or Insurance Company and the amount | Personal “loans advance given to any person or entity including firm, |a‘s! Nel company, Trust etc. and other receivables from debtors and the amount. (vy | Motor Vehicles such a5 wifi |UERO RAHINDED Jeep, Cars Bus, Bae gener Heavy Vehicles (Details 0 | aa Make, registration number. ee rai peste ait ete, year of purchase and |> 243 amount ) with approx. ) present . market -valued 2, 2S according to you iy | Jewellery, Gold, Gold (| Qmaments Sliver and Satves Crnsemesity sala thing{s) (give weight and value) with approx. present .- market value according to you {vil | Any other assets such. as value of claims/interest we Nt Dt kumter La TaSreeteya Dean A eseription cit pose | HUF Prependent-1 pie asseu: E Properties in joint ormership indicating the extent of joint awncrahip will also Oe arr bullding.or apsrtinen shoukd be meslioned Ay i | 2. Fach land of building or apart i mentioned separately in this format Ate oes should include {he intercat in or owncrahip of assets @ | Sexiculiumi Land Lacation(s} Survey a fe fone | AMY onl Mat number(s) ‘Area (total measurement ‘in acres) Hy pet Na ny ray Wi a = = pees thy fant hy Wa wa hy {Yea or No} Date of purchase i : (ea penance eat] 0d | ste wih Bn Ny of self - acquired property Cost of Land fin case of . purchase atthe time of |i) | wy) et phy Ay) Nie} Z Any Invesiment on the fa land by way oof 4 4 a Nn MD ck eat AW FMT oR A Hah ete: “Approximate Current awe it fabh Pow [ote nh wy ru (i) | Nen-Agmeultural Land ae hry Location(s} Survey aA | qh Wy hd number(s} Feiestr ns Mle ‘Area (lotal ditasurement AGP Hs in sq.ft hs Ya. ‘Whether inherited property (es or No} to | re ty Date of purchase in case pein 23-2 ‘of seif- aequired property |, hy Coat of Land fin ease of 3007 jar, purchase) nol 09 reNu oer i) t mt Nit Ni | Mm) Mat Had My i) Wt tet Not Me ull up Area [total tis) Location (3) -Survey number(s} measuirement in sqft) wp May A Wit Whether inherited property ' (Nes or No) iP yf oNey Nel whl a Die of pintchane in ease of self acquived property [ay | play ahh Net wa ht of property fin case of purchase} at dietime ot fea Poi) | ayy tba Mel na purchase Any investment a the | ——S operty by wa i evelopment construction (MMP MNT MTF ayy +a lin ele. ‘Approximate current market saiie Ht aay | Net na Hn ail nit na Way self - acquired property ‘Area (Total mensurement less, 1 wef Mm Built up Area 3 measurement in sq. ft.) PAT) we] Whether inherited —— property Madr] pie (Wes or No} —— Date of purchase ta case of op RC 2eaeet |, thetimert ad 7 np Taveatenent on the =|") w wv of fail By wo i declopinent, construction ["]] iy Appeo market value Others (stich an interest in Property) "4 Hay hy ny Total of current market F value of (ij ta (¥) above my Ny (8) Give herein below the details of liabitties/duea government: ‘and. amount before eae? {@ public financial institutions and ‘se give separate details of name of bank, institution, entity or Description = pouse | Loan or dues to Bank/ Financial Inatitution(s) Name of Bank or Financial —_ Institution, Amount outstanding. Nature of loan NIC} Me | ae ail Team to other” “tndividuaa? aatity other a than mentioned above, r ce ‘Namefs), Amount outstanding, nature of loan wit NIL ‘Any other lability ate niti mecpation) at ea ts nani ity ieee of wouree(s} of Income fay) Deialh (al Bel ih) Me ve, Many, of Meperitenits, 10 Cowernment wid any malilte caripany oF cempaniog (ore (101) Contracts with appropria tered hy the eandlidate cts entered inti by 1 hy depencterits (4) details of contincts entered (d) detaits of contriets entered ftw by Hlrvdhd Und Candidate of spouse or deperutents have interent ... jactn, entered into hy Partnership Firms in which candidate ne Mya Framnily oF test iv wtehy the (e) details of spouse or dependents are partners entcted fala by private companies tn hich candidate or fs if Vafdnion (A) details of contract spouse or dependents have abure (12), My educational qualification (a ax undert ETT b YH bog Pe full form of the certificate/ {Give details of highest School / University education mentioning th diploma/ degree course, name of the School /College/ University aud the year In whieh the course was completed.) VERIFICATION 1, the deponent, above named, da hereby verify nnd declare that the contents of this affidavit are true and correct to the beat of my knowledge and bellef and no part of it Is false and nothing material hus been concealed there from. I further declare that:+ (a) there is no case of conviction or pending cane against me other than (hose mentioned in items 5 and 6 of Part A and B above; (b) 1, my spouse, or my dependenta do not have.any asset or liability, other than those mentioned in items 7 and 8,9 above. Verified ated Erne as bere ioe wh, 209 a woody @ Witnesses Lt Saud kumoy Zagh . 2 Sujit Sinab Dye Sects eer Tire Pris mODISHA BEFORE THE NOTARY PUBLIC, SUNABEDA WHE? 2, SeSnpave'ro BE FILED BY THE CANDIDATE ALONG WITH NOMINATION PAPER TO THE ELECTION OFFICER MOR ELECTION TO THE OFFICE OF THE CHAIRMAN SUNABEDA MUNICIPALITY OF KORAPUT DOISTRICT. For the office of CHAIRMAN of Sunabeda Municipality I, Sri Basant Kumar Tripathy, aged about 55 years S/O Late Ghanashyam Tripathy, resident of Village: Qr. No. u/200, HAL township, Sunabeda-2 PO/PS- Sunabeda Dist-Koraput , Pin NO.763002 a candidate at the above election, de hereby solemnly alfirm and state on oath as under:- 1, [have married one aiid have only one spouse living whose name is Smt, Bharati Mohanty 2. Ihave two children namely:- i) Sidhartha Tripathy ii) Smnuti Rekha Tripathy Verification |, the deponent above named, do hereby verify and declare that he contents of this affidavit are true and carrect to the best af my knowledge and belief and na part of it is false and nothing material has been concealed there from Verifed at Sunabeda this the 6% day of March 2022 Ra teu Lux Tove perth it Depones ‘Witnesses affirmed a7 peaue a) een 2 landp KewmnrRerh, . signed 5o Subys 2 ew Sujit Singh SUNABEDA 9437225203