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INDIA
Be;omeofi dFtrnTr TELANGANA
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(See Rule 4,{)
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AFFIDAVIT TO BE FILED BY THE CANDIDATE ALONG WITH NOMINATION PAPERBETOREfr THE RETURNING OFFICER FOR ELECTION TO MEMBER OFLEGISLATIVP ASSEMBLY (NAITIE OF THE HOUSEI F"ROM SIDDIPET- 33coNsTrBrENcy (NAME OF THE CONSTITUENCYI
PART-A
i. BANS+AL GAJABINKAR Son of KISHAN, Age 60 years, resiclent of H. No. B-S-S2,KanchariEBazor, Sictdipet town and clistrict (mention full postal address ), a candidateat the above election, clo here by solemnly affirm and state on oath as under:
A
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(1) I am a candidate set up by I am contesting as an Independent candidate.
(** strike out whichever is not applicable)
e\ My name is enrolled in Siddipet (Name of the constituency and the State), at
serit No.6ffrn Part No. 95(3) My contact telephone number(s) is/are AC,746590445 and my social media
account(s) (if any ) is/are
(i)......Nil......
(ii)......Nil.
(iii)......Nil
(4) Details of Permanent Account -Number (PAN) and status of filling of Income Tax
return.
(5) Pending crlminal cases
(i) I declare that there is no pending criminal case against me.
lTick this alternatiue e if there is no criminal case pending against theCandidate and utrite NOT APPLICABLE against alternatiae (ii)below)
OR
(ii) The following criminal cases are pending against me :
U. MAI,I.ESHMA' LLB
sl.No
Names PAN The financial year forwhich the last Income-Tax return has beenfiled
Total Incomeshown inIncome Taxreturn(in Rupees)
1 Self NIL NIL NIL2 Spouse NIL NIL NILJ Dependent -1 NIL NIL NIL4 Dependent -2 NIL NIL NIL5 Dependent -3 NiL NIL NIL
,,1,-;'./':-:il A:- I ,i'' :\ i;' rl-'i FiY'; :r.'' ; ::
'I-51' '. r,. l, iA'P,tU,::i !i;.ii, i irs,,t)g
f3*ril //*I
..4..
Table
(6) Cases of conviction
(iil
I declare that I have not been convicted for any criminar offence.(Tick this arternafiae, if the candidate hq.s not been conuicted, q,nd,write NOT AP?LICABLE against alternatiue (ii) below I
OR
I have been convict ted for offences mentioned below;
lrf the cq.ndicate h,,s been convicted, then tick this atternqtiae qnd.score off alternatiae (i) aboae, and, giae detaits in the To,ble below)
(if there- are pending criminal cases against the candidate, then tick thisalternative and score off arternative-1rl abovl,-and give details of allpending cases in the Table belowf
(il
d2fi,r/ d/Elo\,
7---\.
?
OTAsfd tt
(a) FIR No. Withaddress of police Stationconcerned
name and NIL NIL
b Case N,Court
o. with Name of the NIL
NIL
NIL NIL
c Section (s) ofActs/ codes involved (giveDo, of treh section e.g.Section ......of IpC, etc.)
concerned NIL NIL NIL
d Brief description of offence NIL
e IVhetherframed (
have beenchargesmentioned YES
Nol
NIL NIL NIL
answer against (e) aboveIYES, then give the dateon which charges were
framed
If1S
NIL NIL NILf
cb
Appeal/Applicationrevision has been filedag_ainst the proceedings(Men tion yES or NO)
Whether anyfor
NIL NIL NIL
ht
".u**il a V,rilL
;E
\
or
(al Case No. NIL NIL NILb Name of the Court NIL NIL NILc Sections of Acts/ codes
involved (give Do, of thesection e.g. Section ......ofI etc.
NIL NIL NIL
d Brief description of offencefor which convicted
NIL NIL NIL
e Dates ofconviction
orders of NIL NIL NIL
f Punishment NIL NIL NILcb Whether any Appeal has
been filed againstconviction order (Ment onYES or
NIL NIL NIL
h If answer to (Sl above isYES, give details and
status of
NIL NIL NIL
z4:
Table
(6Al I have given full and up-to-date information to my political party about fullpending criminal cases against me and about all cases of conviction as given inparagraphs (5| and (6)
( candidates to whom this Item is not applicable should clearly write NOTAPPLICABLE IN VIEW Op ENTRTES rN S(i) and 6 (if above I
Note :
1. Details should be entered clearly and legibly in BOLD Letter2' Details to be given separately for each case under difference columns
against each item.3. Details should be given in reverse chronological order, i.€., the latest case
to be mentioned first and backwards in the order of dates for the othercases.
4. Additional sheet may be added if required.5' candidate is responsible for supply au information in compliance of
Hon'ble supreme court's Judgment in w.p. o No. s36 of 2oL],.I give herein below the details of the assets (movable and immoyable
4,myself, my spouse and all dependents :
(*a rat
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Noll
aPPeal
fruLES
,]
"':!:y.9)
5:
A. Details of movable assets
Assets in joint narne indicating the extent of joint ownership will alsohave to be given.
In case of deposit/Investment, the details including serial Number,Amount, date of deposit, the scheme, Name of the Bank/Institution andBranch are to be given.
value of Bonds/share Debentures as per current market value in stockexchange in respect of listed companies and as per books in case of non-listened companies should be given.
"Dependent "means parents, son(s), daughter(s) of the candidate orspouse and any other person related to the candidates whether by bioodor marriage, who have no separate means of income and who aredependent on the candidate for their livelihood.
Details including amount is to be given separately in respect of eachinvestment.
Note :1
Note :2
Note :3
Note :4
Note :5
sNo
Description Self Spouse Dependent-1
Dependent-2
Dependent-3
Cash in hand 80,OOO NIL NIL NIL NIL
(ii) Details of deposit inBank accounts(FDRs, TermDeposits and allother types ofdeposits includingsaving accounts).Deposits withFinancialInstitutions, Non-banking financialcompanies andcooperative societiesand the amount ineach such t.
NIL NIL NIL NIL NIL
(iii)
L
Details ofinvestment inBondsdebentures/ shareand units incompanies/mutuai
and othersamount.
NIL NIL NIL NIL
A
'il
/
TAFoNl
9
1\l6b:';:ztU +
i
NIL
?!
(
(iv) Details ofinvestment in NSS,Postal saving,Insurance policiesand investment inany Financialinstrument ts inPost office orInsurance Companyand the arnount
NIL NIL NIL NIL NIL
(u) Personalloans/advancegiven to any personor entity includingfirm, company,Trust etc. and otherreceivables fromdebtors and theamount.
NIL NIL NIL NIL NIL
(vi) Motor vehicles/Aircrafts/Yachts/Ships (Details ofMake, registrationnumber etc. year ofpurchase andamount
HondaActiveTSQTR3678,datedL7-2-2018,worthRs.
15
of
ooo/-
NIL NIL NIL NIL
v11 Jewellery, bullionand valuablething(s) (give detailsof weight and value)
bTHULAS1,OO,OOO
10THULAS2,50,OOol
NIL NIL NIL
vl11 Any other assetssuch as value ofclaims/interest
NIL NIL NIL NIL NIL
Ix Gross Total Value 2,5O,OOO 2,5O,OOOI klt L N,I L Nrt-
B. Details of Immovable Assets
Properties in joint ownership indicating the extent of joint ownership willo have to be indicated.
A"TTESr&
Aro74F*I
4??7
Dv4\
.I.ESITAM
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Note :2 Each land or building or apartment should be mentioned sedparataely inthis format.
sNo
Description Self Spouse
Dependent-1
Dependent-2
Dependent-3
num
LandSurvey
AgriculturalLocation (")
NIL NILNIL NIL NIL
(tota11n
acre
Areameasurement
NIL NIL NIL NIL NIL
Whether inheritedproperty (Yes or No)
NIL No NIL NIL NIL
Date of purchase incase of self-acquiredpropq{ty
NIL NIL NIL NIL NIL
Cost of Land (incase of purchase atthe time of
NIL NIL NIL NIL NIL
Any investment onthe land by way ofdevelopment,construction etc.
NIL NIL NIL NIL NIL
Approximatecurrent marketvalue
NIL NIL NIL NIL NIL
(ii) Non-AgriculturalLand Locations(s)Survey number(s)
NIL NIL NIL NIL NIL
Area (totalmeasurement in sq.
NIL NIL NIL NIL NIL
es or NoWhether inherited NIL NIL NIL NIL NIL
Date of purchase incase of self-acquiredprgperty)
NIL NIL NIL NIL NIL
Cost of Land (incase of purchase
)at the time ofpurchase
NIL NIL NIL NIL NIL
Any investment onthe land by way ofdevelopmentconstruction etc.
No NIL NIL NIL NIL
ESj{.----- rnarket
Approximate..currenttmdqr,e
NIL NIL NIL NIL NIL/
?
hxcrrAs3r\ ta.
vi9.
)u€ tsqL
1
,I
111 Commercialbuilding (includingapartments)Location(s) surveynumbers
NIL NIL NIL NIL NIL
NIL NIL NIL NIL NILArea (totalMeasurement in sq.ft)Built up Area(total measurementin sq. ft )
NIL NIL NIL NIL NIL
Whether inheritedproperty (Yes or No )
NIL NIL NIL NIL NIL
Date of purchase incased of self-acquired property
NIL NIL NIL NIL NIL
Cost of property (incase of purchase )
at the time ofpurchase
NIL NIL NIL NIL NIL
NIL NIL NIL NIL NILAny investment onthe property by wayof developmentconstruction etc.Approximatecurrent marketvalue
NIL NIL NIL NIL NIL
(iv) Residential Budilnings (includingapartments)Location(s) SurveyNumbear(s)
NIL NIL NIL NIL NIL
Area (totalmeasurement in sq.ft)
NIL NIL NIL NIL NIL
Built up area (Totalmeasurement in sq.ft)
NIL NIL NIL NIL NIL
Whether inherited_property (Yes or No)
No NIL NIL NIL NIL
Date of purchase incase of self acquiredproperty
NIL NIL NIL NIL NIL
Cost of property (in
"case of purchase )
i\t, the time of'$;)fohase
NIL NIL NIL NIL NIL
P.LL
l{oreF:x t
U''d r,r t) It fLqf,
Any investment cnthe land by way ofdevelopmentconstruction etc.,
NIL NIL NIL NIL NIL
Approximatecurrent marketvalue
NIL NIL NIL NIL NIL
Other (such asinterest in property)
NIL NIL NIL NIL NIL
vi Total of currentmarket value of (i)
to (v) above
NIL NIL NIL NIL NIL
(8) I give herein below the details of tiabilities/dues to public financial institutionsand government :-
(Note please give separate details of name of bank, institutions, entity orindividual and amount before each item)
I
K:plLESrf44,?'(
f
NgTAFi(\
f
*1,il.'u),./r
s.No
Description Self Spouse Dependent-1
Dependent-2
Dependent-3
i Loan or dues toBank/financialinstitutions(s) Nameof the Bank orfinancial institution,Amountoutstanding Natureof Loan
INDUSIND BANKLTD.HondaActivevehicleLoan Rs.45,OOO/-
NIL NIL NIL NIL
Loan or dues to anyother individua-ls/entity other thanmentioned aboveName(s) Amountoutstanding, natureof loan
NIL NIL NIL NIL NIL
Any other liability NIL NIL NIL NIL NIL
ofGrand totalLiabilities
Rs.45,OOOl-
NIL NIL NIL NIL
,l
f 't3da)rl-
lF
rer/ ov
(ii) Government dues :
Dues todepartment dealing\Mith governmentaccommodation
(A) Has the Deponent been in occupationof accommodation provlded by theGovernment at an time during the lastten year before the date of notificationof the current election ?
(B) If answer to (A) above is YES, thefollowing declaration may be furnished
(il The address of the Governmentaccommodation
(ii) There is no dues payable in respect
of above Government accommodation,
towards
(a) Rent
(b) Electricity charges,
(c) Water charges : and
(d) Telephone charges as on
(date ) { the date should be thelast date of the third month priorto the month in which theelection is notified or any date
thereafter )
Note : No Dues Certificate from theagencies concerned in respect of rent,electricity charges, water charges and
telephone charges for the above
Government accommodation should be
submitted
YES/
NO
No
Dues tcdepartment dealingwith Government
aircraftssport
NIL NIL NIL NIL NIL
a.lr!L
??/
!
htorAltH39.o
\
76q Oy
a f ftuL /.L
tr
1V Income tax dues NIL NIL NILDependent-1
NIL NILSelf Spouse Dependent
-2Dependent-3
V GST Dues NIL NIL NIL NIL NILv1 Municipal lproperty
tax duesNIL NIL NIL NIL NIL
v11 Any other dues NIL NIL NIL NIL NILviii Grand total of all
Government duesNIL NIL NIL NIL NIL
1X Whether any otherliabilities are indispute, if so,mentioned theamount involvedand the authoritybefore which it ispending.
NIL NIL NIL NIL NIL
(9) Details of profession or occupation
(a) Self BUSINESS
(b) Spouse HOUSE WIFE
(9A) Detarls of source(s) of income
(a) Self BUSINESS
(b) Spouse HOUSE WIFE
(c) Source of income, if any, of dependents
(98) Contracts with appropriate Government and any public company or companies
(a) Details of contracits entered by the candidate ...... NIL .........(b) Details of contracts entered into by spouse......... NIL(c) Details of contracts entered into by dependents...... NIL ..........(d) Details of contracts entered into by Hindu Undivided Family or rust
in which the candidate or spouse of dependents have interest ... NIL
Details of contracts, entered into by partnership Firms in whichcandidate or spouse or dependents are partners ... NIL
contracts entered into by private companies in whichor spouse or dependents have share ... NIL
('
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(10) My educational qualification is as under :-
SSC AT GOVE JBS HIGH SCHOOL SIDDIPET
(Give details of highest School/University education mentioning the fullform of the certificate/diploma/degree course, name of the
School/College/University and the year in which the course was completed )
PART B
ABSTRACT OF THE DETATLS GrVEN rN (1) TO (10) OF PART A
\$
11
?
t{C[AFN
1 Name of theCandidates
SRI GAJABINKAR BANSILAL
2 Full PostalAddress
H. No. 8-3-52, Kanchari Bazar, Siddipet town and district.
3 Number andname of theconstituency and State
33 and Siddipet, Telangana State
4 Name of thepoliticalparty whichset up thecandidate(otherwisewrite"lndegendent"
Independent
5 Totalnumber ofpendingcriminalCASCS
NIL
6 Totalnumber
,{flSesr,fiNhtorr?iNed
ofin
NIL
.r. -t, , .^r \.'--i
toc, oy
!'
PANOF
Year for which last incomeTax return filed
Total incomeshown
(a) Candidate NIL NIL NIL(b) Spouse NIL NIL NILO Dependents NIL NIL NIL
B s of Assets and Liabilities in RupeesDetail
Description
Self Spouse Dependant- 1
Dependant-2
Dependant -3
Dependant-4
A MoveableAssets(tota1value)
2,50,000 2,50,000 NIL NIL NIL NIL
B Immovable Asset
NIL NIL NIL NIL NIL NIL
I PurchasePrice ofSelf-acquiredimmovableproperty
NIL NIL NIL NiL NIL NIL
Ii Development/construction cost ofimmovablepropertyafterpurchase (
ifapplicable)
NIL NIL NIL I NIL NIL NIL
III
Approximate Currentmaraketpricea). self-acquiredassets(Tota1Value)(b)inherited assets
NIL NIL NIL
tiesRs NIL NIL NIL
NIL NIL NIL
NIL NILRs. 45 000
(totalValue
ol)l.tI
V
t\!l}q
$oth$sMA II q
ADVOCATE&lrorapi,SIDDIPET-Sa?103.ta F,
Cell' 9dr{i01Sfl{li{I R,dL
dues (Total )
11 Loans fromBankFinancialInstitutionsand others(Total)
NIL NIL NIL NIL V
1o Liabilities that are under diqpgte1 Government
dues (Total )
NIL NIL NIL NIL NIL NIL
NIL NIL NIL NIL NIL NIL
11
VERIFICATION
r, the deponent above named, do here by verify and declare that thecontents of this affidavit are true and correct to the best of my knowledgeand belief and no part of it is false and nothing material has been concealedthere from. I further declare that
(a) Therc is no case of conviction or pending case against me other thanthose mentioned in items 5 and 6 of part A and B above
(b) I, my spouse, or my dependents do not have any asset or liability, otherthan those mentioned in items 7 and 8 of Part A and items 8,9 and 10 ofPart B above
Verilied at Siddipet this the 13tt day of November 201g
DEPONENT2.??7n
f&:,v4.4
NOTAfTVtt
|'.r,g/ I
NIL
11 Loans fromBankFinancialInstitutionsand others
Highest educational qualification
SSC AT GOVE JBS HIGH SCHOOL SIDDIPET
(Give details of highest School/University education mentioning the fullform of the certificate /degree course, name of theSchool/college/university and the year in which the course wascom
LLE
a
Note :1 Affidavit shout be filed latest by 3. pM on the last day of filingnominations
Note :2 Affidavit should be sworn before an oath commissioner or Magistrateof the First Class or before a Notary public.
Note 3. All column should be fiIed up and no column to be left blank. If thereis no information to furnish in respect of any item, either nNil" or Notapplicable as the case may be should be mentioned.
Note 4 the Affidavit should be either typed or written 1egibly and neatly.
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