AFFIDAVIT 1 ",2 9bOI,

Officer... ...... .. ~h. :~(, .. ... ... .. .... ( District f State

/ Union Territory ) 'Mfl.o,.w-t>- . M g'~ Affidavit of Shri 1~,~.:~J~tl___ -S/0-S~-'-_&~~------ ' IM~

1. that I was a contesting candidate at the general election / bye election

to the House of people / Legislative Assembly of ...... 6...3..":: ... ...S!.4;01A C()?"~ from .. ... .. .2 ..~~~0,. ...... .. . .. .. .... Parliamentary / A~sembly Constituency f the result of which was declared on .. ./S?!F2-!'9.-eJ 11­

2

\

2

2. that I /my election agent kept a separate and correct account of all

expenditure incurred / authorized by me/my election agent in connection

with the above election between .!J...l//.v..~/c.( the date of which I

was nominated ) and the date of declaration of the result thereof , both

days inclusive.

3. that the said account was maintained in the Register furnished by the

Returning Officer for the purpose and the said Register itself is annexed

hereto with the supporting vouchers/ bills mentioned in the said account.

4. that the account of my election expenditure as annexed hereto includes all

items of election expenditure incurred or authorised by me or by my

election agent, the political party which sponsored me , other associations

/ body of persons and other individuals supporting me , in connection with

the election , and nothing has been concealed or Withheld / suppressed

therefrom ( other that the expense on travel of 'Leaders \\ covered by

explanations 1 and 2 under section 77(1) of the Representation of the

People Act, 1951 )

5. that the abstract Statement of Election Expenses annexed as Annexure- II

to the said account also includes all .expenditure incurred or authorized by , '1 "" . . .. me, my election agent, the pol it ical party which sponsored me, other

, "\ . ~ ~:7' iJssociations/ body of persons and other individuals supporting me , in me Of ~

. That the statements in the foregoing paragraphs 1 to 5 are true to my

personal knowledge, that nothing is false and nothing material has been

concealed . ~ Deponent

Solemnly affirmed /Sworn by .... .... ....at this .... day of / .f()./!ij,D/7-beiore me

___ _

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

__ __ __ _ _

Anll cxll r c - l S

111"- Name or Stal<.:/~I T<mitory

[V

_.__._----­ ---­ ____ ____.J

Date: I Plilce: ~tv\ ~"'-

pcl\ciilUl'eP~niclllars '\1111. Incurred J Alith. by C""didaleJ Eltelioll agcilt(in

_____._ __.----.---- - -~<'~L_____

AmI. Incurl'cd! aUlhoriled by 1'01. f'nrl},

AmI. IncllI'l'cu / uUlhori zed by others (ill Ks.)

T"lal r-:le~lion c.~

(}l1(4) .-(5)

([II I(s.)

_______---+-____~_ _ __

.L___¥--._------

--I-------~-,--------- -

'-QD l q;J'----lj _ .__ _ _ _._._ _____

-~-_. - - .

__~_ ..___ ,,_, -

_- 'f:xI';;;;:';;:-';-i;;-r;'lbiiC 1Il~;;ling:' l'uJly, ;.~(le~s sioll elc.: _ 1 4

f. a: I~xpcnscs in Pllblic llleelillS, ml.ly, 'PI'",;cs"ioll etc_ (ie: other Ihall the one·s wilh Star Cnmp;ligllcrs of the Political partyI (Lncios\! as~I' Sdtcllllle-l) ~ . ._.____ __

-----j:-h:!:;xpc;tditure ill pl;]JITC~;-f;;g-'~1i1Y:'----procession etc_ whh the Star CUll1pa;hllel{S} (ic: olher Ihan those fli)' gencrnl paTl)' \)rop;'l-\,lIlua} (~Ilclosc l1';"J~.r)che~ule.21.__•__ ._________

-Cumpaign malerial s other th,m Ih()!: ~ Itscci ill lhe ,() QII public nll,!!tillg. mlly, processioll ,d.,. ni,nlioncd in _ j~ 0 .,/ S,N().I__~~~vc(Ellclosc as pCI' Sch~.c!:J~~~:]2--'___I-__ ________ -jC1Il111iligll, thrOllglt p rint and clcctlwik: med ia inciliding cablc IId\vurl< . blilk SM~ or,inlernet olill

__ ,_~ Soci~lllJcdiaEncl~,::-'!.~ J.1cr ,~ll~,~l k.:iL_____ __ _ _

III

r::JT -- --- -· · · jl..:...: ft.¥>IV'------_...L'i;~pClldi[llre 0!2..::~.'!.~,!iBll vehiclc(sL~~~~d bL______ ----- .- .,- .__ . ... _­

S N() 'J; l"li ctllars ----­ - -----------­ - - -­--­- - - ~l00 I~::--i ----2----­- -­ .. ­ --­ 3 ---­ --­ -­

11---- Amolillt or own fUlld used fo, the ~kcii()n cl,n p.ti gll - - -­ - - iJ J~ __ __ -1~:~£Io~c'~_ p crSclJ~~_"_:2L ___ ______ _ _ _________ M T., v

~ 1I Llimp ~uln 1l00ll11IlIICCC IVed fro lll th e PllIt)' (;C. ) III cosh 01 d"'(]lIt' Ci C . N U- ('1 '--~)

__ __ ("nclos_,,-!'syCi $clwdlilc -H) _____ _ ,_ __1.__ ___~_ __.___ ___ _ III 1.\lI11P SllIll amollnl I\~"dvrd no III OilY person! company/ lirool "ss()C iot i on~ I hody of persons J I,' P

ew. as loon, gill 01 donation elc' tv J

1

__ l : n<: ,~~rc-,-_Schcdlll~_:Y)Total ------ ,

--- ---­ - ----- ­ - ...---, . -.~-------

? o -- - --·-'----­- ­ --­- --­ -- ---1---r: I>

' _I

1.1 , '

. ~

-----------

I I-.----:-T"""";,.--rr---;I-----''--:-----,rt- ­

Schr.<lulcs- 1 111 9: DelHils of Elc\'lions I'IIIIUS IlI lll EXpclldil llrc ufC,uulidalc

---_.

ISclle~:_I_. .- - .- - . 1 Expcnse~ in public meeting, r~lIy, pruc<:-s, iul\ etc. (ic: othel' than those with Star Call1pnigncrs of Ihe POlil_ic"_ ___ _ ____ ­_ 1pa rlY~. .

S. No Nalun; ur Expendilure Towl,\\IlOlIllt Source Of _E_X C_'I_\(_li_lt_" ·_C_ _ . •_---1 in Rs. r

AmI. AIIII. .'\1111. ! incurred f ill cll rrc(\ , Aullt. by

incurred f by 1"01. hy olli"I'

Candidlilc f Party wilh I agent name I

I 2 - - .. ..... _ ---_._ -_._--­

6-'-- f--------------- --------...,..,-- - t-- -------t----- ­ ----.-- - - ­ -1I Vehicles fOl' tran5pol'ting I'isitors -'2 Ert:t:tillg Slag~, Pandal & FUrIlitllrc. Fixtllres, poles etc. I

Arches &. fJarl'icadcs 01C. f----j------------·---..- ---·----I - ­ - -_.-/---_._ - - - -- .

,1 Flbwcrs/ garlands!-._- - , ----_._ _ .- _... ------·--1I 5 Hiring I.OIlU sp(;~kcrs , Microphonc, al1lpliticrs, COIll]larcrs etc.

~--~. I~bilh, pa~s, nan., ~rS, Cut.(;:;;:\O~~clingS ·1 lii~-_. .. ~Jl~~;;~~~=-Itt~~~~~-;rr ..--_--.-I!__ ==-_~~~~!;-.~~~~~,~~ ,..= - ...~.... 7 Beverages like tea,_Water, cold drin" . juice etc. 1----- .. _----_·_ - ----_...._-_· _ .. _ ---- - - ---+-------+-- --1 8 Digitlll TV -boards rlisplay, Projec:or display. tickers board s, 3D

display -~'- --_._-----------..._-_.._-- --_. -_...- ..--- _. 9 E'p0 I1SC~ on celebrities, paymcnt to mus icjon~, olher artists

n:mulleralioll etc.

nil1a!i-~~~:.I~ ,I'- ~_I-IIOI--+"--II-tl- -S=I=ik=C==sc=.r-i~-I-I-.~fi.--b-~~.~~"~~._I -~-'_tc=.===~_-_-_-- ..-·-.. - ..---:-..-----.-.---.- ---+------.-- ---- - .- -~~l Expenses 011 IJ'nnsporl, Hclicopte.-! ~ ; r.:ran! I'chicl ~~/ Dunts cle. chnrt',cs ( for scJf, celebrity or any other campaigner other thall i

f-_ __I-S_t_al_·C_all1paign~r) _____.._.._____...____ _ __. ____._._._ ..._ ......._. __ .i

12 POWCI' con~llmptioll/ generatol' charges - II

----- - - -.'--.-.- - - - ---- -.. ,,---- - --t--- --..... -.--- .. .. - .. -- -- _. . 1J Rent for venue

- - _ ._ -----------_._-----_.. ------+----- --_.- ...__ ._...---j _1'_I _ _ ~~ sccwity chnrg~__.....___ ....___..._1 15 [l oardjll~ & lodging expenses of ~el~, celebrity, party

functionary or any OTher campaigner ;ncluding Star Campaigner - - - --------_.. _ --_..... _ -------- - 1----­16 Others expenses

....- - -'---_.---- . ---- .-.----------.­Total , _._-- ---- _._-------------_._----- ­

Sche(Iule- 2 AI•A -' _ _____'-..:1_ ___.______-,'-'-_y ________

Expenctillirc in public lIleeting rully. procession elc. wilh the Sl~r C~mp'ligncr(s) as npponiollcu 10 cHtluidalC (i.c.: other IIwlI Iho~e

for gencmlllnrty propaganda)- - _._---------_...__.. _-- _.._-_._--_._----- --- - ------_._._.

[

S. No Date and Venue

..._---_._.----. 2

Name of tile SI;1/' . ymo\lnt or Expenditure on publk rllceting RelllMk::, Camp~igncr(5) &. Name ridly, procession etc. with the S tar if :lily

of Party ' . ' ('mllpnigner(s) npflOl"li'1ilcd to the C:llididf\i.c (As othcr than for !\0l1cntl party propa g<indiJ) in Rs.

- -- ­ - ­ - ---.---pf"---­ ---­ .. -. - ..----­ ---+-- ­

-f- ­ -,- ­ - - - -

Towl

, hC(llllc-3

S-oo-.::>

_------"-Q~> 5 .. .?_.______..__ ..._

.-/ c I

l!lll. By I ~nJidaie agcnr

I - ­.-.'"--- ­

. ~ - ­' -.----­

--' -- ­ --­ .-A\lli. By Amc By Pol. Pm1y otilers

5 6

1'1-->0 - ­_ 0._'_ - '--­ -_.... 1--­ -----­I>"~ 0 -2£"30 -...- ­ - - .--­

_ ____._____ _ -­ Ir9flo,---'.. - - ­ ,--­ --- ­

- _ __ ~ .-_______....- . - -----_..·. _ 1

[)~tnils of expenditure Oil cHlnpaign ",,,tcl'i:1Is, like han<lbil 'ls, pllInph IdS, pv.sters, ho"rdill~s, banners. cut-Ollts, gates & arches, video I'

:llld audio C<l5settes, CDsI DVDs, Loud ~pcakel's, ampliticrs, digital TV! bO;\ld di splay, J D display etc. for calldidnle'selection campaigll ( i.c.: other thnn those covcreu ill Schedule- I & 2) I S No. Natul'e of Expellses Total Amount ill Rs. SOLllce;; of Expenditure ,R~II;;k;-~··~ny !

Total_______ .....L._

Schedllle- <\ }J.',l---_._--_. -_._----- ----.- ._ .... _ .__.__._- - .. _...... .. __. ...... ... .. . .. ..--"~"

Details of expenditure on campaign through print ftllti electronic \ll~<lin includillg cable net.work, b"lk SMS or illtCrnel or social media, news items/TV/radio c!Ja~\I\eJ etc·., including the p~id news so (/~cided by MCMC or voluntarily admitted by rhe eal\didate TIi~ details should incluue the expenditure incurred on all such news :tcins arpearing ill privately owned ne\Vsp~persITVh,'dio cilllilllCls etc.,

S. No Nature of llIeclium (ei ectronic I print) nnd durarioll

Name Hnd address of media proviJer (print Ielectronic ISMS I voicel cablc

k TV, SOCIal media "t,- ) o 0

I .. - -2--·---- '3---

- ---.- -------, Namc ~nd address or agency, reporter, stringer, company or . AmI. By AmI. 13y AmI. By i any rersoll to wholll !candidate! Pol. \'(11 t)' others I[

; charges / cOllllni~sioll ~ agcnt etc. paidf payahlc. if [ • IV i "I , . _ .. __.• . 1

_. 'I -· 5·---·-=-1- . 7·--·=~.c:=J- -·----.......,-'+- 6----I

-1--­

------­- -t---.. ­-----~~V---------~ -----------

4

TOlnl

Schedule- 4/\ NA -----,------+--)J --=__~ I V"'~

Details of expenditure 0 11 c'Hllpaign Ihruugh pnnland electronic media including cable network, bllik SMS 01' inlct'llCI or ~(x;ial Illedin, news itcJl1s/TV/rndio channel etc., ind"dillg the paid news so deciued by ,"feMe or vululltarily <ldmincd by lile calldid~le. The details should include iile e,tpcuditurc incurred on all such news items appearing ill ncwspapcr:\lTVhadio chanl\~Is, OWlleci by tite candidate 01' by the pulilic;" party sponsor 'ng-thc c;indidatc

S.No. Nfttllr~ ofmcdi:;-;;;- Name and IN.llne mid nddrc,~ ofl~;-Olol ArnOL"\~R-;- Sources of [Xl'en~~e------ 11

(eleclronic/ print) iaddress ofmed;" agellcY,lepOiler, -r-- '­ -and dllrnliol1 'provider (print stlillger, company 01 1\011 Oy 11\1111. ny Ami Ily

Ielectronic IS MS ~,Ily person to whom cnnrlid~tc/a PilI. r'arty 0Ih"r~ I / vQic e! Coble cI\~rgcs I cOlnl11i:;sillll Col. (3) +(·1) gent :

TV, soci;ilillcdia etc. p~idl p"y~blc, if I'.

ctc.) ally ----- --~--.--- -------- _.. ---­~~. --­ .__ .__ .

2________ J'1 5 6 7_____!___ 2

2 - ­ --------1----­

_.._____ _ _ L.:.._ ___ _

Tota l

Schedule -5 -------------- --------- --­ -_._ - -------- ------------Demils of expenditUre on campaign vt'hide «and poll expcndilure 011 vchicJe(s) for c~ndidate's election campaign

S~ Regll. No. of--jl-Jiri;,g Ch.lIg~~-~\'cI~i~lc l~;:-- To;-;;-'-- Soulce IlfE~ I~;;d;~;;- --Vehicle &0 Type or I DilYs for mnL

Vehidc R ~ I" l'uci Driver's winch incIIIJ-ed/ -Ann By- 1\- -8 -'­ .'\nll B)'ale or 111111<:; . used auth ;n ml. y

of vehi()le l charges . candidate/ Pol_ Part)' olhers f

Rs. Illaintcnnnc~ (I not agent

covered tinder

- ---­ 1-­ ----­ --­--­-­ .­ .... .­7

I'

_ _ __

- ---- - - -

fSJ T " z~~r~l t'1~.J- -~E -jSCIlCd ulC- 6 .... - -­

IUctai Is of expcll (iitllrc on ClIllpaign work~rs I a(;Clll$ ,, ~;'d Oil C;l ll diclatc:;' booth ~(ki"' ks) oUlside polling staliollS f~~ di ~tl' i blltioll 0/'

~

vutel's slips -------------r-.- -.-------­

___.­______-+-_ __-\__. _ __

- - --- -­

--­.... ­ - - -- .--.­

I _..--.-_._­ .....­ ---SNo. Date Cash DOl Cil<" •.juC no. etc. with

detai Is of dl'awce b'lI1k . Tolal Amount in lb. il.enlQrks

-------+-----.,------l~---- ----.----f_--

--­_ .._.._ -......._-----­ - - --_ .._ ----­ _..._-­_ ... _...- ­ - _ .-.. -­ - ....­ --. Schedllle- 8 .------­ .....------------.---­ .-..­ ..- .......--~-----------..­ _.. - ---"_.._ - -----­/)etDils <)f Lump sum 3mollnt received ii'om the pml)' (ie5) in cash or cheqLle or DD or by ACCOLlIII Trans rer

~S.-N~~ [N""" ""h, I""" ---­-·--­=EC"'h--- IDD! CI;;q,," '" "k w;", """",~r ~~ -tl~~-;;;;~k~ Political Pmly ,J,'awee bnnk I if nny

L I Am I ....._ ...... _ ___•____._ .. ,,_ _ ____ ___ __._.....__1___.. _ ..__._ __.______ _ _...--l

Expenses 011 Campaign workels

Nuture ~f'- Rate Expenses

S. No Date and Velllie

2 Jb --- +----_ ._ -­ ,,------- ­ .- --­

,-­J .-­4

5

Canel ielalcs' uoolhs(Kiosks) set lip for eliS[I'ibutioll of vOIer's slipst;tj?§ ~;:;::g,, ----+----

(f(f" honorari.ullli ~_-..!:-D.l ~_ ~~Iary etc. ___ _____

Boarding .--- - .--- - -. --. - _ ·_---- -----1----­

__ Lodging -­-f--- -- -.---- ,---. - ----- .--.- ­ --.­Others

.._ _ _..____ ! o_l_fi_1___.___ ___ ______ _ ._______ __

Schedule- 7

-nc tnils· of i\lil0unt of own fund used for the election cnrnpnign

---..-.-- ------'--- - --- ---'--- - - -

Tolal ami. in cull\:o/ Somet> of LXPCllcli l LlreINo. Of' . HUt!1. In t{s. Aillt. l1y Am!. [l y

workers / candida /e/ 1'01. ['a rty a.,,-ents/N o. ;w;cnl ofKiosb "I

Jc G

---.---~.-----.---I----.

-,, - - _. ._~~

1\1111. By others

7

....._ .._ 1

. ----..._-- ----"'~tL.. -.-"-~-~¥

-t------. 2

2

3 ~--Sch~d ll k.. 9 H·p ._.....­ -.

Delaib of LlImp sum ~Il\Olllll received from .'1 \), Jl( rS\lIl/colI\pany/fjllll/n~"O<:Jntiollsl ll ody of persons elc

Tot~1

S. No. Name dnd "ddr~s_~ Dale Cash

2

2

3

L Total._-L...__._ ___ _ ___.. • ____._ __ _._.. __

----+---=---.--.---. ~

___ -~ -: . Note : I. it) Schedule 5: ..

-----_._---- - ­011111

ill Rs.

- '--'- ­5 6 "I4 ------1-------- - ---- ­

" .. --=:~=--

_

I

-.--'-----:~ T~~~L -------.----~~

as loan. ~-ft ol-:Ion ::r~- I DOl Cheq ue no . elc. Menlion whether .1"01;1 Renwrk s willI deta ils of lo~n, gin or I dr~wcc bank . donatioll etc. Alii

I ollnt in Rs. I

I -----.,-- --- "'1

··--- --~I=_~=_ I

~~ ~~b~J'""._

(~) copy 01'11,,· order containing list llf ~ .·I vehicles for which pcnllil iss lied by Ih,! Retllrnin g OrliCH to b<: enclosed. eb) Irille vehicle is owned by Ihe can<,'.d<lrdhis relative/agent arc lIsed for election purpose, notionnl eost ill' hire llf all slich vehicks_ except OIlC vehicle if own' ~d and used by the candidate. llotiol\~1 Co,1 or rllt:! ane drivers siilnry for ' slIch w hicle, sh~I1 be included in tot~1 am.ol":1 of expenditure in Ihe abov~ table. 2. In fill sche(hlks if any expcnditure OI!gnoos and services. provided by the Pulitica l Party; (lr provide,c1 by <\ny person/ comp<lnyf linn Inssociotionsl I)-Jdy of persons etc. 011 behalf of the ca ndidate, then the 110[iollol Illarkcl vHllI" of sue)l goods ur services ~re to be inl~ic<lte.d, in respe ctive COIUII1I1 5.

J. In I'ar[ -- III, tile LlJmp~s llrn OlllClunl of frllld rccci\'ed fr'O,ll the politicil l party or others or the c<lnditlate's own n,nd~, should be men tioned date wj~". III "II such cases slich amoullts fire requireulo be lirsl deposited ii, till; bank nccullnl urthe Cilild idalc, orclicd fen ,;kctioli expenses. 'I. Each page of the Abstract StatcnKIl' should be signed by the c,1I1cii!iatc

[