2
Form 26
(See rule 4A)
Affidavit to be furnished by the candidate before the returning officer for election to -----
-------------- ------------------------(name of the House) from -------------------------------------
constituency(name of the constituency)
I, ----------------------, son/daughter/wife of ------------------------------- aged about -
-------------------------years, resident of ----------------------------------------------------
candidate at the above election, do hereby solemnly affirm/state on oath as under:-
1. I am/am not accused of any offence(s) punishable with imprisonment for
two years or more in a pending case(s) in which a charge(s) has/have been
framed by the court(s) of competent jurisdiction.
If the deponent is accused of any such offence(s) he shall furnish the following
information :
(i) Case/First information report No./Nos. ……………………………..
(ii) Police station(s) ……………District (s) …………….State(s)……..
(iii) Section(s) of the concerned Act(s) and short description of the offence(s)
for which the candidate has been charged …………………………….
(iv) Court(s) which framed the charge(s) ……………………………………
(v) Date(s) on which the charge(s) was/were framed ……………………..
(vi) Whether all or any of the proceeding(s) have been stayed by any court(s)
of competent jurisdiction ……………………………………………….
…………………………………………………………………………..
2. I have been/have not been convicted of an offence(s) [other than any offence(s)
referred to in sub-section (1) or sub-section (2), or covered in sub-section (3), of section 8
of the Representation of the People Act, 1951 (43 of 1951)] and sentenced to
imprisonment for one year or more.
If the deponent is convicted and punished as aforesaid, he shall furnish the
following information:
(i) Case/First information report No./Nos. ………………………………….
(ii) Court(s) which punished …………………………………………………
(iii) Police station(s) ………………District (s) … ………State(s)…………..
(iv) Section(s) of the concerned Act(s) and short description of the offence(s)
for which the candidate has ever been charged ………………………..
(v) Date(s) on which the sentence (s) was/were pronounced …………………
(vi) Whether the sentence(s) has/have been stayed by any court(s) of
competent jurisdiction …………………………………………………
Place Signature of
deponent
Date:
------------------------------------------------------------------------------------------------------------
VERIFICATION
I, the above-named deponent, 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 therein.
Verified at -------------------------this ----------- --day of -------------,20—
Signature of deponent
Note: The columns in this Form which are not applicable to the deponent may be struck
off.”
(See rule 4A)
Affidavit to be furnished by the candidate before the returning officer for election to -----
-------------- ------------------------(name of the House) from -------------------------------------
constituency(name of the constituency)
I, ----------------------, son/daughter/wife of ------------------------------- aged about -
-------------------------years, resident of ----------------------------------------------------
candidate at the above election, do hereby solemnly affirm/state on oath as under:-
1. I am/am not accused of any offence(s) punishable with imprisonment for
two years or more in a pending case(s) in which a charge(s) has/have been
framed by the court(s) of competent jurisdiction.
If the deponent is accused of any such offence(s) he shall furnish the following
information :
(i) Case/First information report No./Nos. ……………………………..
(ii) Police station(s) ……………District (s) …………….State(s)……..
(iii) Section(s) of the concerned Act(s) and short description of the offence(s)
for which the candidate has been charged …………………………….
(iv) Court(s) which framed the charge(s) ……………………………………
(v) Date(s) on which the charge(s) was/were framed ……………………..
(vi) Whether all or any of the proceeding(s) have been stayed by any court(s)
of competent jurisdiction ……………………………………………….
…………………………………………………………………………..
2. I have been/have not been convicted of an offence(s) [other than any offence(s)
referred to in sub-section (1) or sub-section (2), or covered in sub-section (3), of section 8
of the Representation of the People Act, 1951 (43 of 1951)] and sentenced to
imprisonment for one year or more.
If the deponent is convicted and punished as aforesaid, he shall furnish the
following information:
(i) Case/First information report No./Nos. ………………………………….
(ii) Court(s) which punished …………………………………………………
(iii) Police station(s) ………………District (s) … ………State(s)…………..
(iv) Section(s) of the concerned Act(s) and short description of the offence(s)
for which the candidate has ever been charged ………………………..
(v) Date(s) on which the sentence (s) was/were pronounced …………………
(vi) Whether the sentence(s) has/have been stayed by any court(s) of
competent jurisdiction …………………………………………………
Place Signature of
deponent
Date:
------------------------------------------------------------------------------------------------------------
VERIFICATION
I, the above-named deponent, 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 therein.
Verified at -------------------------this ----------- --day of -------------,20—
Signature of deponent
Note: The columns in this Form which are not applicable to the deponent may be struck
off.”
3
10
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 :
11
(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.
12
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)
13
(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
14
(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
-----------------------------------------------------------------------------------------------------------
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 :
11
(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.
12
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)
13
(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
14
(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
-----------------------------------------------------------------------------------------------------------
Form 26
(See rule 4A)
Affidavit to be furnished by the candidate before the returning officer for election to -----
-------------- ------------------------(name of the House) from -------------------------------------
constituency(name of the constituency)
I, ----------------------, son/daughter/wife of ------------------------------- aged about -
-------------------------years, resident of ----------------------------------------------------
candidate at the above election, do hereby solemnly affirm/state on oath as under:-
1. I am/am not accused of any offence(s) punishable with imprisonment for
two years or more in a pending case(s) in which a charge(s) has/have been
framed by the court(s) of competent jurisdiction.
If the deponent is accused of any such offence(s) he shall furnish the following
information :
(i) Case/First information report No./Nos. ……………………………..
(ii) Police station(s) ……………District (s) …………….State(s)……..
(iii) Section(s) of the concerned Act(s) and short description of the offence(s)
for which the candidate has been charged …………………………….
(iv) Court(s) which framed the charge(s) ……………………………………
(v) Date(s) on which the charge(s) was/were framed ……………………..
(vi) Whether all or any of the proceeding(s) have been stayed by any court(s)
of competent jurisdiction ……………………………………………….
…………………………………………………………………………..
2. I have been/have not been convicted of an offence(s) [other than any offence(s)
referred to in sub-section (1) or sub-section (2), or covered in sub-section (3), of section 8
of the Representation of the People Act, 1951 (43 of 1951)] and sentenced to
imprisonment for one year or more.
If the deponent is convicted and punished as aforesaid, he shall furnish the
following information:
(i) Case/First information report No./Nos. ………………………………….
(ii) Court(s) which punished …………………………………………………
(iii) Police station(s) ………………District (s) … ………State(s)…………..
(iv) Section(s) of the concerned Act(s) and short description of the offence(s)
for which the candidate has ever been charged ………………………..
(v) Date(s) on which the sentence (s) was/were pronounced …………………
(vi) Whether the sentence(s) has/have been stayed by any court(s) of
competent jurisdiction …………………………………………………
Place Signature of
deponent
Date:
------------------------------------------------------------------------------------------------------------
VERIFICATION
I, the above-named deponent, 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 therein.
Verified at -------------------------this ----------- --day of -------------,20—
Signature of deponent
Note: The columns in this Form which are not applicable to the deponent may be struck
off.”
(See rule 4A)
Affidavit to be furnished by the candidate before the returning officer for election to -----
-------------- ------------------------(name of the House) from -------------------------------------
constituency(name of the constituency)
I, ----------------------, son/daughter/wife of ------------------------------- aged about -
-------------------------years, resident of ----------------------------------------------------
candidate at the above election, do hereby solemnly affirm/state on oath as under:-
1. I am/am not accused of any offence(s) punishable with imprisonment for
two years or more in a pending case(s) in which a charge(s) has/have been
framed by the court(s) of competent jurisdiction.
If the deponent is accused of any such offence(s) he shall furnish the following
information :
(i) Case/First information report No./Nos. ……………………………..
(ii) Police station(s) ……………District (s) …………….State(s)……..
(iii) Section(s) of the concerned Act(s) and short description of the offence(s)
for which the candidate has been charged …………………………….
(iv) Court(s) which framed the charge(s) ……………………………………
(v) Date(s) on which the charge(s) was/were framed ……………………..
(vi) Whether all or any of the proceeding(s) have been stayed by any court(s)
of competent jurisdiction ……………………………………………….
…………………………………………………………………………..
2. I have been/have not been convicted of an offence(s) [other than any offence(s)
referred to in sub-section (1) or sub-section (2), or covered in sub-section (3), of section 8
of the Representation of the People Act, 1951 (43 of 1951)] and sentenced to
imprisonment for one year or more.
If the deponent is convicted and punished as aforesaid, he shall furnish the
following information:
(i) Case/First information report No./Nos. ………………………………….
(ii) Court(s) which punished …………………………………………………
(iii) Police station(s) ………………District (s) … ………State(s)…………..
(iv) Section(s) of the concerned Act(s) and short description of the offence(s)
for which the candidate has ever been charged ………………………..
(v) Date(s) on which the sentence (s) was/were pronounced …………………
(vi) Whether the sentence(s) has/have been stayed by any court(s) of
competent jurisdiction …………………………………………………
Place Signature of
deponent
Date:
------------------------------------------------------------------------------------------------------------
VERIFICATION
I, the above-named deponent, 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 therein.
Verified at -------------------------this ----------- --day of -------------,20—
Signature of deponent
Note: The columns in this Form which are not applicable to the deponent may be struck
off.”
1
FORM 2B
(See rule 4)
NOMINATION PAPER
Election to the Legislative Assembly of...................................................State.
STRIKE OFF PART I OR PART II BELOW WHICHEVER IS NOT APPLICABLE
PART I
(To be used by candidate set up by recognis ed political party)
I nominate as a candidate for Election to the Legislative Assembly from the
.......................................................................................Assembly Constituency. Candidate's name.........
...................…..…………[Father's/mother's/husband's name] ........................................................ His postal
address................................…………………………………………………. His name is entered at S.
No............. .....in Part No. ...................... of the electoral roll for ..................................................... Assembly
constituency. My name is ................................…………….. and it is entered at S. No.................. in Part
No. ............................. of the electoral roll for the ................................…………… Assembly constituency.
Date ....................................... (Signature or proposer).
-------------------------------------------------------------------------------------------------------------------------------
PART II
(To be used by candidate NOT set up by recognised political party)
We hereby nominate as candidate for election to the Legislative Assembly from
the..................................……………..Assembly Constituency.
Candidate's name ............................................................................………….. Father's / mother's / husband's
name.............................................…..His postal address.........................…………...............................………
His name is entered at Sl. No...............................in Part No............................of the electoral roll
for.....................………………………… Assembly Constituency.
We declare that we are electors of this Assembly Constituency and our names are entered in the electoral
roll for this Assembly Constituency as indicated below and we append our signatures below in token of
subscribing to this nomination:_
Particulars of the proposers and their signatures.
Electoral Roll No.
of proposer
Sl. No.
Part No. of
electoral Roll
Constituency
Sl. No. in that
part Full name Signature Date
1. 2. 3. 4. 5. 6.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
________________________________________________________________
N.B.:_ There should be ten electors of constituency as proposers.
PART III
I, the candidate mentioned in Part I/Part II (Strike out which is not applicable) assent to this nomination and
hereby declare_
(a) that I have completed..............................................years of age;
[STRIKE OUT b(i) OR b(ii) BELOW WHICHEVER IS NOT APPLICABLE]
(b) (i) that I am set up at this election by the................................................party, which is recognised
National Party/State Party in this State and that the symbol reserved for the above party be
allotted to me.
(ii) that I am set up at this election by the......................................party, which is a
registered-unrecognised political party/that I am contesting this election as an independent
candidate (Strike out which is not applicable) and that the symbols I have chosen, in order of
preference, are:-
(i). ........................................…...(ii)…......................................................(iii)..….............................................
(c) that my name and my father's/mother's/husband's name have been correctly spelt out above
in............................... (name of the language)
(d) that to the best of my knowledge and belief, I am qualified and not also disqualified for being
chosen to fill the seat in the Legislative Assembly of this State.
*I further declare that I am a member of the............................**Caste/tribe which is a scheduled
***caste/tribe of the State of....................……….in relation to …….…………………..(area) in that State.
I also declare that I have not been, and shall not be, ****nominated as a candidate at the present general
election /the bye-elections being held simultaneously, to the Legislative Assembly of ………………….
(State) from more than two Assembly Constituencies.
Date....................... (Signature of Candidate)
______________________________________________________________________________________
*Score out this paragraph, if not applicable.
**Score out the Words not applicable.
N.B._A "recognised political party" means a political party recognised by the Election Commission under
the Election Symbols (Reservation and Allotment) Order, 1968 in the State concerned.
______________________________________________________________________________________
PART III A
(To be filled by the candidate)
Whether the Candidate –
(i) has been convicted –
(a) of any offence(s) under sub-section (1); or
(b) for contravention of any law specified in sub- YES/NO
section (2), of section 8 of the Representation of the People
Act, 1951 (43 of 1951); or
(ii) has been convicted for any other offence(s) for which he has been
sentenced to imprisonment for two years or more.
If the answer is “Yes”, the candidate shall furnish the following information:
(i) Case/First information report No./Nos…………………………………………..
(ii) Police station (s) …………..District(s) ………………State(s) ………………..
(iii) Section(s) of the concerned Act(s) and brief description of the offence(s) for
which he has been convicted ……………………………………………………….
(iv) Date(s) of conviction(s)…………………………………………………………….
(v) Court(s) which convicted the candidate ……………………………………………
(vi) Punishment(s) imposed [indicate period of imprisonment(s) and/or quantum of
fine(s)]………………………………………………………………………………
(vii) Date(s) of release from prison………………………………………………………
(viii) Was/were any appeal(s)/revision(s) filed against above conviction(s)…Yes/No
(ix) Date and particulars of appeal(s)/application(s) for revision filed ……………….
(x) Name of the court(s) before which the appeal(s) /application (s) for revision filed
………………………………………………………………………………………
(xi) Whether the said appeal(s) / application (s) for revision has/have been disposed of
or is/are pending ……………………………………………………………………
(xii) If the said appeal(s)/application(s) for revision has/have been disposed of -
(a) Date(s) of disposal ………………………..
(b) Nature of order(s) passed …………………
Place :
Date : (Signature of the candidate);
PART IV
(To be filled by the Returning Officer)
Serial No. of nomination paper......................................................................
This nomination was delivered to me at my office at.............................(hour)
on........................(date) by the *candidate/proposer.
Date....................... .Returning Officer
________________________________________________________________
*Score out the word not applicable.
________________________________________________________________
PART V
Decision of Returning Officer Accepting or Rejecting the Nomination Paper
I have examined this nomination paper in accordance with section 36 of the
Representation of the People Act, 1951 and decide as follows:
Date....................................... Returning Officer
(Perforation).............................................................................................................
PART VI
Receipt for Nomination Paper and Notice of Scrutiny
(To be handed over to the person presenting the Nomination Paper)
Serial No. of nomination paper......................................................................
The nomination paper of..................................………………a candidate for election from
the ...........................................Assembly constancy was delivered to me at my office
at......................................................(hour) on......................................... (date) by the
*candidate/proposer.
All nomination papers will be taken up for scrutiny at................................... (hour)
on...................................................(date) at..........................................(Place.)
Date.............................................- Returning Officer
(See rule 4)
NOMINATION PAPER
Election to the Legislative Assembly of...................................................State.
STRIKE OFF PART I OR PART II BELOW WHICHEVER IS NOT APPLICABLE
PART I
(To be used by candidate set up by recognis ed political party)
I nominate as a candidate for Election to the Legislative Assembly from the
.......................................................................................Assembly Constituency. Candidate's name.........
...................…..…………[Father's/mother's/husband's name] ........................................................ His postal
address................................…………………………………………………. His name is entered at S.
No............. .....in Part No. ...................... of the electoral roll for ..................................................... Assembly
constituency. My name is ................................…………….. and it is entered at S. No.................. in Part
No. ............................. of the electoral roll for the ................................…………… Assembly constituency.
Date ....................................... (Signature or proposer).
-------------------------------------------------------------------------------------------------------------------------------
PART II
(To be used by candidate NOT set up by recognised political party)
We hereby nominate as candidate for election to the Legislative Assembly from
the..................................……………..Assembly Constituency.
Candidate's name ............................................................................………….. Father's / mother's / husband's
name.............................................…..His postal address.........................…………...............................………
His name is entered at Sl. No...............................in Part No............................of the electoral roll
for.....................………………………… Assembly Constituency.
We declare that we are electors of this Assembly Constituency and our names are entered in the electoral
roll for this Assembly Constituency as indicated below and we append our signatures below in token of
subscribing to this nomination:_
Particulars of the proposers and their signatures.
Electoral Roll No.
of proposer
Sl. No.
Part No. of
electoral Roll
Constituency
Sl. No. in that
part Full name Signature Date
1. 2. 3. 4. 5. 6.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
________________________________________________________________
N.B.:_ There should be ten electors of constituency as proposers.
PART III
I, the candidate mentioned in Part I/Part II (Strike out which is not applicable) assent to this nomination and
hereby declare_
(a) that I have completed..............................................years of age;
[STRIKE OUT b(i) OR b(ii) BELOW WHICHEVER IS NOT APPLICABLE]
(b) (i) that I am set up at this election by the................................................party, which is recognised
National Party/State Party in this State and that the symbol reserved for the above party be
allotted to me.
(ii) that I am set up at this election by the......................................party, which is a
registered-unrecognised political party/that I am contesting this election as an independent
candidate (Strike out which is not applicable) and that the symbols I have chosen, in order of
preference, are:-
(i). ........................................…...(ii)…......................................................(iii)..….............................................
(c) that my name and my father's/mother's/husband's name have been correctly spelt out above
in............................... (name of the language)
(d) that to the best of my knowledge and belief, I am qualified and not also disqualified for being
chosen to fill the seat in the Legislative Assembly of this State.
*I further declare that I am a member of the............................**Caste/tribe which is a scheduled
***caste/tribe of the State of....................……….in relation to …….…………………..(area) in that State.
I also declare that I have not been, and shall not be, ****nominated as a candidate at the present general
election /the bye-elections being held simultaneously, to the Legislative Assembly of ………………….
(State) from more than two Assembly Constituencies.
Date....................... (Signature of Candidate)
______________________________________________________________________________________
*Score out this paragraph, if not applicable.
**Score out the Words not applicable.
N.B._A "recognised political party" means a political party recognised by the Election Commission under
the Election Symbols (Reservation and Allotment) Order, 1968 in the State concerned.
______________________________________________________________________________________
PART III A
(To be filled by the candidate)
Whether the Candidate –
(i) has been convicted –
(a) of any offence(s) under sub-section (1); or
(b) for contravention of any law specified in sub- YES/NO
section (2), of section 8 of the Representation of the People
Act, 1951 (43 of 1951); or
(ii) has been convicted for any other offence(s) for which he has been
sentenced to imprisonment for two years or more.
If the answer is “Yes”, the candidate shall furnish the following information:
(i) Case/First information report No./Nos…………………………………………..
(ii) Police station (s) …………..District(s) ………………State(s) ………………..
(iii) Section(s) of the concerned Act(s) and brief description of the offence(s) for
which he has been convicted ……………………………………………………….
(iv) Date(s) of conviction(s)…………………………………………………………….
(v) Court(s) which convicted the candidate ……………………………………………
(vi) Punishment(s) imposed [indicate period of imprisonment(s) and/or quantum of
fine(s)]………………………………………………………………………………
(vii) Date(s) of release from prison………………………………………………………
(viii) Was/were any appeal(s)/revision(s) filed against above conviction(s)…Yes/No
(ix) Date and particulars of appeal(s)/application(s) for revision filed ……………….
(x) Name of the court(s) before which the appeal(s) /application (s) for revision filed
………………………………………………………………………………………
(xi) Whether the said appeal(s) / application (s) for revision has/have been disposed of
or is/are pending ……………………………………………………………………
(xii) If the said appeal(s)/application(s) for revision has/have been disposed of -
(a) Date(s) of disposal ………………………..
(b) Nature of order(s) passed …………………
Place :
Date : (Signature of the candidate);
PART IV
(To be filled by the Returning Officer)
Serial No. of nomination paper......................................................................
This nomination was delivered to me at my office at.............................(hour)
on........................(date) by the *candidate/proposer.
Date....................... .Returning Officer
________________________________________________________________
*Score out the word not applicable.
________________________________________________________________
PART V
Decision of Returning Officer Accepting or Rejecting the Nomination Paper
I have examined this nomination paper in accordance with section 36 of the
Representation of the People Act, 1951 and decide as follows:
Date....................................... Returning Officer
(Perforation).............................................................................................................
PART VI
Receipt for Nomination Paper and Notice of Scrutiny
(To be handed over to the person presenting the Nomination Paper)
Serial No. of nomination paper......................................................................
The nomination paper of..................................………………a candidate for election from
the ...........................................Assembly constancy was delivered to me at my office
at......................................................(hour) on......................................... (date) by the
*candidate/proposer.
All nomination papers will be taken up for scrutiny at................................... (hour)
on...................................................(date) at..........................................(Place.)
Date.............................................- Returning Officer
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