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FORM 26

(See rule 4A)

an

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AFFIDAVIT TO BE FILED BY THE CANDIDATE ALONGWITH NOMINATION PAPER BEFORE

THE RETURNING OFFICER FOR ELECTION TO (NAME OF THE HOUSE)

FBOM .. CONSTITUENCY (NAME OF THE CONSTITUENCY)

PART A

r-tged

**son/Caughter/wife cf

...... years, resident of

;;,;;; ;., .;;; ;, ";,J[:::::utr

Postar acidress)' a candidate atthe above erection' do herebv soremnrv

(1) I am a candidate setup by

(** name of the political party)/'i"i';1in i:ontestirrg as an lndependent candidate

('"i'strike out whichever is not applicable)

(2) My name is enrolled in ....................

Serial No. ........... in Part No.

(Name of the constituency and the State), at

(3) My contacttelephone number(s) is/are

and my email id (if any) is ..

and my social media account(s) (if any) is/are rtt\

(i)(, ,\

(ii) ,r6t

(i

Please atfix yourrecsrt passport

size photograph

here

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(4) Details of Permanent Account Number (PAN) and status

Note.-lt is mandatory for PAN holder to mention PAN and in case of no PAN. lt should be" No PAN allotted ".

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Sl. No. Names PANfor which the

lncome-taxreturn hasbeen filed

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Self

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(5) Pending criminal cases

(i) I declare that there is no pending criminal case against me.

lTick this alternative if there is no criminal case pending

NOT APPLICABLE against alternative (ii) belovt)

OR

(ii) The following criminalcases are pending against me :

llf there are pending criminalcases against the

score off alternative (i) above, and give details of all

Table

(6) Cases of conviction

(i) I declare that I have not been convicted for any criminal

lTick this alternative, if the candidate has not been

against alternative (ii) below)

t

tive and

below)

APPLICABLE

+

write

OR

(ii) I have been convicted for the offences mentioned below :

Llt the candidate has been convicted, then tick this alternative and score off

above, and give details in the Table below)

J

(a) FIR No. With name and address of

Police Station concerned.

(b) Case No. with Name of the Court

C( ) Section(s) of concerned Acts/Codes

involved (give No. of the Section,

e.g. Section ........... of lPC, etc.\.

(d) Brief description of offence

(e) Whether charges have been framed

(mention YES or NO)

(f) lf answer against(e) above is YES,

then give the date on which charges

were framed.

(g) Whether any Appeal/Application for

revision has been filed against the

proceedings.

(Mention YES or NO)

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ctsr sqr&r €rs-*dT frcqftm swqrqr sTrt. ,^,ll/ Nto\ow lubtlc ^,LAst or. *.r-1111** W{/-

Regd.No. 9t)3 G"iv

Dist Nandsd

tflF

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(a) Case No.

(b) Name of the Court

(c)

(d) Brief description of offence for which

convicted.

(e) Dates ol orders of conviction

(f) Punishment imposed

(g) Whether any Appeal has been filed

against conviction order.

(Mention YES or No).

(h) lf answer to (g) above is YES, give

details and present status of appeal

Table

(6A) I have given fulland up-to-date information to my political

against me and about all cases of conviction as giverr in

criminalcases

and (6).

lcandidates to whom this ltem is not applicable

VIEW OF ENTRIES /N 5 (i) and 6 (0, abovel

NOT APPLICABLE IN

Noles:

1. Details should be entered clearly and legibly in BOLD letters

2. Details to be given separately for each case undei'different,cslumns against each item.

3. Details should be given in reverse chronological order, ie., Ihe iatest case to be mentioned

first and backwards in the order of dates for the other cases-

4. Additional sheet may be added, if requireo.

5. Candidate is responsible Ior supplying all information in compllance of Hon'ble Supreme

Court's judgment in W.P (C) No. 536 of 2011

(7) That I give hereinbelow the details of the assets (movable and immovable etc.) of myself , rny

spouse and all dependents :

A. Details of movable assets :

Note ; 1 . Assets in joint narne indicating the extent of joint ownership will also have

Note :2. ln case of deposit/lnvestment, the details including Serial Number, Amou

deposit, the scheme, Name of the Bant</lnstitution and Branch are to be

Sections of Acts/Codes involved

(give no. of the Section,

e.g. section .......,............ of lPC, etc.).

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?-r0r Ashok B. Jadhav

Regd.No. 9u3 G.rvt. of MHDist Nanded

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Nofe :3.

Note :4.

Note:5.

Note;6.

(o

Value of Bonds/Share Debentures as per current market value in Stock Exchapge in

respect of listed companies and as per books in case of non-listed ccgrpanies should

be given. '+-

' Dependent ' means parents, son(s), daughter(s) of the candidate or spouse and any

other person related to the candidate whether by blood or marriage, who have no

separate means of income and who are dependent on the candldate for their livelihood.

Details including amount is to be given separately in respect of each investment.

Details should include the interest in or ownership of offshore:ossets.

Explanation -For

the purpose of this Form, the expression " " includes, details

body or institutioncf all deposits or investments in Foreign Banks

abroad, and details of all assets and liabilities in

Table

(ii)

Sl.No Description Self Spouse HUF Deperdent-2 Dependent-3

(i) Cash in hand

Details of deposit in Bank accounts

(FDRs, Term Deposits and allother

types of deposits including saving

accounts), Deposits wrth Financial

lnstitutrons, Non-Banking Financial

Companies and Co-operativesocieties and the amount in each

such deposit.

(i ii) Details of investrnent in Bonds,

debentures/ shares and units in

companies/lVIutual f unds and

others and the amount.

(iv) Details of investment in NSS,

Postal Saving, lnsurance policies

and investment in any Financial

instrumentsin Post off ice orlnsurance Company and the

amount.

(v) Personal loans/ advance given to

any person or entlty including firm,

company, Trust etc., and other

receivables from debtors and the

amount.

I

(vi) Motor Vehicles/ Aircrafts/Yachts/ Ships (Details ol Make,

registration number etc. year of

purchase and amount).

4g:(vii) Jewellery, bullion and valuable

thing(s) (give details of weight and

value).

l/+'$ rs

I*iqr. t,\ -"€j ".

(viii) Any other assets such as v a I u e

of claims/interest

\{

(ix) Gross TotalVaiue

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Ashok & JadhavRegd.No. 903 Govt. of trilH

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Dist I'

/

/

q1

B. Details of lmmovable Assets:

Note 1 : Properties in joint ownership indicating the extent of joint ownershi6:ittillbe indicated.

also.a

have to

Note 2

Note 3

Each land or building or apartment should be mentioned separately in this format

Details should include the interest in or ownership of offshore assets.

(i)

S.No Self Spouse HUF Dependent-1Description Dependent-2 Dependent-3

Agricultural Land Location(s)Survey number(s)

Area (totai measurement in

acres)

Whether inherited property(Yes or No)

Date of purchase in case ofseltacquired property.

Cost of Land (in case ofpurchase) at the time ofpurchase.

Any investment on the land by

way of development, const-ruction etc.

Approximate current marketvalue

N on -Ag ilc Lrit u ra I

Location(s)

Survey number(s)

Land

Area (total measurement in

sq.ft.)

Whether inherited property(Yes or No)

I

Date of purchase in case of

self -acquired property.

Cost of Land (in case ofpurchase) at the time ofpurchase.

Any investment on the land by

way of development, constru-

ction etc.

Approximate current markelvalue ACommercial Buildings (including

apailments)-Location(s)

-Survey numbe(s) \Area (total measuremenl in

sq.ft.)

,rN

(iii)

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S.No. Description Self Spouse HUF Dependent-1

Built-up Area (total measurement

in sq.ft.)

Dependent-2 Dependent-3

Whether inherited property

(Yes or No)

Date of purchase in case ofself-acquired properly. I

I

I

Cost of property (in case ofpurchase) at the time ofpurchase.

Any investment on the property

by way of development,construction etc.

Approximate current marketvalue

Residential Buildings(including apartments)-Location(s)

-Survey numbe(s)

Area (total measurement in

sq.ft.)

Built up area (Total measure-

ment in sq.ft.)

Whether inherited property(Yes or No)

Date of purchase in case ofself -acquired property

Cost of property (in case ofpurchase) at the time ofpurchase.

Any investment on the land

by way of development,corrstruction etc.

(iv)

Approximate current marketvalue A

(v) Others (such as interest in

propefty) ,,,,,Y,,2

Total of current marketvalue of (i) to (v) above

(vi)

f,r

$,KE

a'

Rq

(a) *, srfl ?milifl, mdqHfi fuflq rilst'qr q yrnmrqr qrfu-diqTliq rmqtlT nq{frm *o snt :-(H, : F'tl-qt q.Fq, {iFlE[, ql(ssrq FFqr qiHEr qlq qqt gdT nq{nf, (s-{ sflcF qlslRt-rtR {*F-q uI-q.L)

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---Ashok B. Jadhav

'Regd.No. 903 Cl;vt. of MftDist Nandod

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(8) I give herein below the details of liabilities/dues to public f inancial institutions and government :-(Note ; Please give separate details of name of bank, institution, entity or indivicli-:al and ariiount

before each item) - \

*

Description Self Spouse HUF Dependent-1 Dependent-2 Dependent-3

Loan or dues to Bank/financial

institution(s) Name of the Bank

or financial lnstitution, Amount

outstanding, Nature of Loan

Loan or dues to any other

individuals/entity other than

mentioned above Narne(s),

Amount outstanding,

nature of loan

Any other liability

Grand total of liabilities

Government dues :

Dues to Departments dealing

with Government

accommodation

(A) Has the Deponent been in occupation of

accommodation provided by the Goyernment at

any time during the last ten yearsbefore the

date of notif ication of the current election ?

(B) lf answer to (A) above is YES, the following

declaration may be furnished namety: -

(i) The address of the Government

accommodation:

(ii) There is no dues payable in respect of above

Government accom modation, towards-

(a) rent;

(b) electricity charges;

(c) water charges; and

(d) telephone charges as on

(date)

( the date should be the last date of the third

month prior to the month in which the election is

notified or any date thereafter).

Note- ' No Dues Cefiificate 'from the agencies

concerned in respect of rent, electricity charges,

water charges and telephone charges for the

above Government accommodation should be

submitted.

YES/NO

(Pl. tick the

appropriate

alternative)

ffi

S.No.

(ii)

(i)

( iii) Dues to depafiment dealing with

Government transport (including

aircrafts and helicopters)

:

I

l,l

i1i\{ei

(iv) lncome tax dues

I

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/' otltQtotary r ublic

@,qrer#-cqH

Ashok B. Jadhav\egd.No. 903 Govt. of tulH

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(9) Details of profession or occupation :

(a) Self

(b) Spouse

(9A) Details of source(s) of income :

(a) Self

(b) Spouse

(c) Source of income, if any, of dependents,

(98) Contracts with appropriate Government and any public

(a) details of contracts entered by the candidate

(b)details of contracts entered into by spouse

(c) details of contracts entered into by dependents ..,,

(d) details of contracts entered into by Hindu Undivided Family ortrust in which the candidate

(e)details of contracts, entered into by Partnership Firms in which candidate or spouse or

dependents are partners ..

(f) Details of contracts entered into by private companies in which candidate or spouse ordependents have share

(10) My educational qualification is as under :-

(Give details of highest School/University education mentioning the fullforrn of

diploma/degree course, name of the School/College/University and the year in

was completed.)

\c

S.No. Description Self Spouse HUF Dependent-1 Dependent-2 Dependent-3

(v) GST Dues

(vi) Municipal/Property tax dues

(vii) Any other dues

(viii) Grand totalof all Government

dues

(ix) Whether any other liabilities are

in dispute, if so, mention the

amount involved and the

authority before which it ispending.

+

lel

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,l

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t I

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havt. of Mh,d

Ashok B Jad

4eod.No 903 C'-''

Dist Nande

I

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PART.B

(11) ABSTRACT OF THE DETATLS GIVEN lN (1) TO (10) OF PART-A

Name of the candidate Sh./Smt./Kum

i-1

Z Full postal address

3 Number and name of the constituency and State

4 Name of the political party which set up the

candidate (otherwise write'lndependent')

5 Total number of pending criminal cases

b Total number of cases in which convicted

7 PAN of Year for which last

income Tax return

fited

Totalincomeshown

(a) Candidate

(b) Spouse

(c) HUF

(d) Dependent

B Details of Assets and Liabilities (including offshore assets) in Rupees

Description Self Spouse HUFT

Deoendent-l lr Deoendent-l I'lI

I

Dependent-lll

A Moveable Assets

(Totalvalue)

B lmmovable Assets

l. Purchase Price of self -

acquired immovable

property

ll. DevelopmenVconstru-

ction cost of immovableproperty after purchase

(if applicable)

lll. Approximate Current :

market price-

(a) self-acquired

assets(TotalValue)

(b) inherited assets(TotalValue)

ffii*qil

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fficrqsTrfrr qd'qi-sr aqvfle urqr.)

s-q flYTqr"Tuffid frrenrT q ynHmaffi I

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t" ublicJadhavGovt. of Mh

Nanded

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Description Self Spouse Depeldent-lllHUF Dependent-l Dependentll

I Liabilities

(i) Government dues

(Totai)

(ii) Loans from Bank,

Financial I nstitutions

and others (Total)

10 Liabiiities that are under

dispute

(i) Government dues

(Total)

Highest educational qualification :

(Give details of highest School/University education mentioning the full form of the

certificate/diploma/degree course, name of the School/CollegeAJniversity and the year

in which the course was completed.)

(ii) Loans from Bank,

Financial I nstitutions

and others (Total)

1

,

) c

a,

I g

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fi

fr

tr

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ryd*'-{dr GiT srTfrT frrq6 3rTt. qrdf, ffi qrT u}a t+r& q Rl({ sturatfr q-f,mTsi rfq ?gt{ ffi cTEi ci srr"rs}

trffErsTfuH 6ldl61,-

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frET ffi s.flr ycikf, arfr.

(s) *, rilEft c-"frzqT-sr rfi H-qT cr-Eswr €rqeqq qrT 3T ql qlfr \e q e qE+ oillur

qFT s qT qr* 3, 1o 4 K uE+ ra< drd-flr eT-ffiflfrffi'Swom & Sr

ftqffi 8(rni-f t-+{ffirfudAd sTtsEFO

ry Public, R.No.903.of Maharaehtra sfi{qGft

B. Jadhav Adv.

-oo

2

qrum q-rsqrf, qrA

dq r : yrqerqa t vrqrr sTr{ffi ffi'qr wrq *uft ffirsrt fu-qT dq qqus qiqr€ck vt$ffiq oT oqro qrd.

dq q : ud r*-fi *nrd oilfu ffi renr+ firff ArA qM eT-+qT rftiqra qrfl siTqqrql qrtrfr q{ sd-frqto nr ' frt*. ' toh-fl " qqlftqfr HTI"rS " qt ;r{i m-<o-qro qrd.

*q x : yrqerq{ \'s-f,{ ffifu'frsd.frq {qlqqli lHH-d q qqRra srsrd.

*q q : yrsen,nafi u?+'fi y€Tq-r srfi{qEfl* Erqrfr qtcr{irdF e+rt. cT qfrkffi ytqqq:{rnfi q'dm. y]Elq{ +.fr

f+-er yrcpr oTr{-ffi 6q1qsftr*r$ qiqr srrfi yrprq, {-ifiefr ird t-d erQa rqisT iflffir sr+n-sl.

R+4t:-l--

(rl

+6oyr. ot

(M.s.)

'lontifled By Me

r^8 ocowom & IBEFO

+4

(

tSp'

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o.a.

*q t : yrqsrq,r t ilqfrftrq qrea q'tuqrqr taegT

{i

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RY

l, the deponent, abcrre named, do hereby verify and cleelare that the contents of this affilavifwe f rue

aricj correct to the best of my knowledge and belief and no part of it is false and nothing materiai has oeerr

concealed there from. I further declare that :-(a) there is no case of conviction or pending case against me other than those mentioned in items

5 and 6 of Part A and B above ;

(b,1 i, rry spouse, or nry dependents do not have any asset oi liability, other than those rnentioned

in iterns 7 anci 8 of Part A and items B, 9 and 10 of Part B above.

Verified at .this the day of

DEPONENT

a

\

I

Note: 'l

Note 2

Nofe: 3

Nole: 4.

Note: 5.

Affidavit should be filed latest by 3.00 PM on the last day of filing nominations.

Affidavit should be sworn before an Oath Commissioner or Magistrate of the First Class

or before a Notary Public.

All column should be filled up and no column to be left blank. lf there is no information to

furnish ir' respect of any item, either "Nil" or "Not applicable" as the case may be, should

be mentioned,

The Affidavit should [:e either typed or written legibly and neatly.

Each page of the Affidavit should be signed by the deponent and the Affidavit should bear

on each page the stamp of the Notary or Oath Commissioner or Magistrate before whcrnr

the Affidavit is sworn.

Yr€-mq qqq-dT g*urcr+, iffi

i

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