Neelam Rani

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