Neelam Rani

mB,
lneutive l{agistnr
Ralenn* 04qtltn
ANNEXTJRE-II
Before the Returning officer
For election to Municipal Committee -Kalanaur
From tcaarc( No-o4 ConstituencY.
AffBAVIT
lNEStrA!{ nR$I' S/O,D/o,Wo Shri mtx}!
aged 5o Rlow.No.6
V&PO: Kalanaur, tehsii:Kalanaur, distt.Rohtak do here by solemnly affirm and declare
as follows:-
1. That I have filed my nomination papers forthe above election.
Z.That,in connectionwith mycandidature fortheabove election,I am submitting
herewith the in formation , under section 8 of the Representation of the people Act,
t95t d sdr -sertiun (t) of scretim t3A of t*rc I+anyma 'tmieip* Aet tg?3infrE
prescribed Affidavit & proforma.
3. That the information furnished in the enclosed
proforma is true to the best ofmY
knowledge andbelief andthat nothing material
Place:Kalanaur
Datel7 10512013
.+,
has been concealed there from.
.W\Sfl
DEPO
Verified before me
I Knaro ,t-,
-A A+- -U,> Orz/.-n4
(Signature of veriffing
authority with seal)
?a ' 5-'?3 fnamcdOrW

L*_
Poforma for furnishine information under section 8 of the Repfesentation of the
Peoole Act "1951
and sub-section(1) of section 1$A of the Harvana Municiual Act
1973 hv everv randidale atan election to DlunicinflIitier-
Election to the Municipal Committee - Kalanaur
From tpqre( No -o A
-ward.
Name of the Candidate . NaJ'a""^
Fathedrtethor/tlusband's Name : ^r,--n
lvl r^"rln- /*r-?
PART-I
(Iofomslioa lrndel Section I of tle Representation of fhe pople A41"1.95 U
1. Have you ever been convicted : N Q tter b**^ C..'*vr'lzo{ W u-5-
by a Court of law:- Ourt sf /-

3. Was any appeaVapplication for :
revision filed against above Conviction
{+ Refrr:ence'Ns-gfeff^UrpPljcation :
for revision filed,If any.
(ii) Date of filling of such appeaUapplication:
For revison.
(iii) Name of the court before which the
AppeaUapplication for revision fi led.
(rv) Whether the said appeaVapplication
For revision has been disposed of or
Pending.
(v) If disposed of :-
(a) Date of disposal :
(b) Nature of order passed :
(vi) Whether any bail granted during :
the pendency of appeaVappliciation
for revision.
(vii) If yes , period during which remained on:
Bait.
YesA.Ior-l
N,fl,
N.fr .
N.n .
N'4 .
N.fr-
N-A-
/,1.4.
Disposed of /Pending. Nt PeA;n*lbb-
A,*rfaa*.1
PART-II
( In formation under Section 13 A(1) of the tlaryana Municipal Act.L973)
4.
5.
Have you ever been disqualified by or under any
law for the time being in force for the purposes of
election to the Legislature of the State of Haryana.
Have your everbeen disqualified by or under any
law made by the Legislature of the State of Haryana'
YesA{o y'
YesA{o t/
PLACE:Kalanaur
DATE :2dt0512013

AI\INEXURE.III
( Order No.SECIE-fiIr2003/18831, Dated 06.10.2005)
Aflidavit to be furnished by candidate along with nomination paper before the
Returning Officer.
Note:-
l.
2.
J.
*1.
*t
*3.
Affidavit shall be prepared on a non-judicial stamp paper/document
paper(pucca paper) and sworn before the First Class Magistrate or a
Notary Public or a Commissioner of Oath appointed by the High Court or
before the Sub-Division Offiser (Ciyit) /Tehsildtr / Naib Tehsildar
(conferred with the powers of Executive MagisEate) havingiuxisdiction to
the area.
**,f f.3.d.
Ftease read the contents of the Annexure carefutty and strike the contents
not ryplicable teyo+r.
X'or the election to the office of Sarpanch of Gram Panchayat
Name), Block
(Name).
For the
OR
election to the o{Iice of Member for ward No. of*
Gram
Samit
Panchayat
(name)
(Name) or
jtc
Zila
Panchayat
Parishad
,(Name).
OR
For the election to the oflice of Member ,for ward No. O/ of *
Municipal Corporation
Council (Name) or *
{Name}.
I N.ez
0 ^,,,^ &o'j== :t#,
Wo Shri lvl ,c/ey- | f
aged Ao yedrs, resident of W.No. p/ ,
Kalanaur,
sub-tehsil:Kalanaur, distt. Rohtak catdidate at *re abwe eleetion, do here
by solemnly affirm and stale onoathas under:-
(strike out whichever not applicable)
1, I have, in past ,been convicted of,a criminal of&nce in the following
cases and the details are as under :-
r)
ii)
Case No.
Noer C.*,,uir-J;le..( {$ s^.
\ (-.,r,.<
A) Section of the Act and descripion of the offence for which
convicted d.H .
Note''r'r* Not applicable in the case of Municipalities
*r'rc*z Word Declaration has been deleted by notification
No.,SEC/E -111/200311A527, dated 30-10-2003.
**&*3 tlead Note No.2 was deleted by notification No.SEC/E- IIY
2A0U Lg 527, daled 3 0- I 0-2003.
iii) Dates of conviction
iv) Courts by which convicted

v)Punishmentimposed(indicateperiodofimprisonmentawarded
q.rl6 puuhitr"a*rf
and /or quantum of fine imposed). Nevev 'Mpo*a(
vi) Detaitsifappealdrevisionetc. fihdaboveeosrvi'etions' rl-*'
2. That I have in the past been discharged /acquitted in the following
cases:-
r) Section of the Act and description
"{ P" offerce with which
charged. 7'l evor D/t"cl^'^,?24 / fi'')"ft*l
ii) Case No- N' *.
iii) N.arne ef tlrccourt by whioh mqtritta#discharggd N'ft'
iv) Date of acquittall discharge N' fl '
v)Detailsofappeals/applicationsforrevisior/review,Ifany,filed
against above acquittaUdischarge' N'fl '
3.Thatlhave,inperiodendurgsixmonthspriortothedateoffiling
T}rcp+eserrtnorni**tion,beerrrccusodoftkf+uowi**goff,e*ces'
Pwrisabtetrithimprisormreffwithtwoy€affiormorE,trIdinmhich
a charge has been framed or cognizance taken by the Court as
indicatedhereunder: - ltlo oa'y- cha'r74 fl"*1 ?*rftff
(Note:- This excludes the cases mentioned in (l) and (2) above)" (:'sl-'
i) Section of the act a$d descriptim of the offence with
whish ehrgd /eognizmee tdceru N' n
ii)Thecourtwhichhasframedthecharge/takencognizanceIN.fr.
iir) Case No.
N' fr
1v) Date of order of the court framing charge/taking
cognizance, fl' fr '
v)Detailsofappeal.s/applicatioosforrevisionetc'ifaay'filed
*gainst above ordcr framing /t*klng cognizarrce' N'fr '
* Sffie out which is not aPPlicable'
drrYf,m

L*
4) That I give herein below the details of the assets ( immovable, movable,
balaree e.te')of my self, my spurse ad deper&ats* :
A. Deffi of movatle assefs
( Assets in joint name indicating the extent ofjoint ownership will also have to be
given)
S.No.
Description Self Spouse
Name
Dependent.
1 Nfrfi€
D€pesdent
-2 Name
Depemdent-
3 Nane
(i)
Cash
?oP*f
(ii)
{iii}
(ro
(v)
(vi)
(vii)
Deposits in
Banks, Financial
ffiionsand
NonBauking
Financial
Companies
Bo*ds,
Debentures and
shares in
Companies
Other Finarrcial
instruments, NSS,
Postal Savings,
LIC Policies, etc.
Motor Vehicles
(details of make,
etc.)
Jewellay Gire
details of weight
and value)
etrrer assets, sreh
as values of
claims/interests.
?r'y'-
N-t
lN
N^1
hrtd
a Te(q
1utver
3Tak"
Nrl
Note VaSe of Ronds/shares/debentrre-s as ptr g6s latesf, merket value in stock
exchange in respect of listed companies and as per books in the case of non listed
companies should be given.
*Bsf€r*derrt hre rcansa perso+ substmtially dcpe*r+ts,oa'he ircme ofeandidate' _>.
., rta'z 8ll

B.
Details of Immovable Assets
ft{ote: Pr€perti€E injsirt qrn*b' in irfuing ftE€xt€ffi ofjsirt ovmerstb wiltatso
be indicated J.
Sr.
Description self Spouse(s)
Dependent-
Dependnet-
Dependent-
No.
Name(s)
lName
2 Name
3 Name
(r) Agricultural
land -locationssurvey
mffiers-
Exfents(Tofal
measurement)-
curent market
vafue
{ii) No* -
Agricultwal
Land-locationssurvey
hkmhs-exte#
(Total
measurement)
current market
mhre
(iii) Buildings
(commercial
and residential)-
Locafionssrvey/&or
numbers- extent
(total
measurement)
effirsfitmaket
value
(rv)
{v}
Houses/Apart
ments etc.
Buildings
(eomereid
and residential)-
Locations -
survey/door
Nrnrbers-
Extents (total
measurement) -
current market
vafue
O.&ers{swh*s
interest in
properly)
W
N-il
Nrx
'{rt
Nnl
t\
-Efl
\

5) I give here inbelowtte details ofmyliabititieVover dues to public financial
institutions and government dues:-
:Please
details for each items
S.No. Description Name and address of
Bank/financial
Institutions/Departments
(aXt) Loans from Banks
(ii)
Loans from financial
institutions
N)L
Nr'I
Amounts
outstanding as on
(iii)
(bxi)
(ii)
(iii)
Government dues (other than
income tax and wealthtax)(No
dues certificate to be enclosed
in case holding or having held
any public office).
Income ta:r including
surcharge[Also indicating the
assessment years upto which
Income Tax Return filed .Give
also permanent Account
NumberGAN)I.
Wealth Tax{ AIso indicate the
assessment year upto which
wealth tax return filedl.
Sales Tax [only in case of
oroorietary business'|.
lvrl
N;/
N,r(
Nrl
(iv) fiupffiTa;r
Nil
6) My educational qualifications are as under:- 5+t .
( GIVE DETAILS OF SCHOOL AND UNIVERSITY EDUCATION)
(N*" of school/Universrty and the year in which the courtre w[s completed :09uld
arsobegiven) Kt\F\q ftrtl
PLACE:KALANAUR
DATED:2 "10512013
DEPONENT
Name in full
VERIFICATION
I , the deponent above named , do here by verifu 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 J#;fi;h;ffiil'
verifiedat Kalanaur thisthe
$rt^vfiw zot3. 6fidl
n --