4"L. * Strike off whichever is inapplicable. ... I.._ '-..' .. - I._=... /fa""/*/e~ ted..!3.../ikt.&.;wtz... ACKNOWLEDGEMENT FORM

Transcription

1 ~. ACKNOWLEDGEMENT FORM '-..'... - ~ < TO THE RETURNNG OFFCER, 4"L. Sir, acknowledge receipt of your letter No... /fa""/*/e~ ted..!.../ikt.&.;wtz... along with its enclosures containing, among other documents, a Register bearing serial No... for maintaining of my accounts of election expenses.. have noted the requirements of law for maintenance of account of election expenses and lodging of true copy of that account with the Distrlct Election Officer Returning Officer. Yours faithfullyra S& * Strike off whichever is inapplicable..a. +.~.:Lie ~ _= _ i- -

2 ABSTRACT STATEMENT OF ELECTON EXPENSES 7 Name of the Candidate Number and name of Constituency Name of State/Union Territory V Nature of Election (Please mention whether General Election to State Assembly / Lok Sabha / Bye- election) V Date of declaration of result V Name and Address of the Election Agent V f candidate is set uo bv a oolitical PART - -.& / &m.a: G7) k/c; mlh.&a./ - party, Please mention the Aame of the political party A d h ~ V Whether the party is a recognised Yes/&S political party //-4-7Q/7 #&a[ %". Date: 4-. a 7 Place: 'w. Signature of the Candidate x.

3 PART- : ABSTRACT OF STATEMENT OF ELECTON EXPENDTURE OF CANDDATE S. No. Particulars Amt. Amt. Amt. ncurred ncurred/ ncurred / Auth. by authorize / ()+(4)+(5) Candidate d by Pol. authorize / Election Party d by agent(in (in Rs.) others Rs.) Expenses in public meeting, rally, procession etc.:-. a : Expenses in public meeting, rally, procession etc. (ie: other than the ones with Star Campaigners of the Political party, (Enclose as per Schedule-). b : Expenditure in public meeting rally, procession etc. with the Star Campaigner(s) (ie: other than those for general party -maganda) (Enclose Campaign materials, the public meeting, rally, procession etc. mentioned in s.n~. above(~nclose as per Schedule-) Campaign, through print and including cable network, bulk SMS or internet (Enclose as per Schedule-4) 7.97 V V on campaign vehicle(s), used by candidate(encose as per schedule-5) Expenses of campaign workers / agents (Enclose as per Schedule 4) Any other campaign expenditure Grand Total PART : ABSTRACT OF SOURCE OF FUNDS RASED BY CANDDATE S No Part~culars Amount (~n /o. s6.7tri Amount of own fund used for the eleron campalgn (Enclose as per Schedule - 7) - Lump sum amount received from the party (ies) in cash or cheque etc. (Enclose as per Schedule -8) Lump sum amount received from any person/ company/ firm/ associat~ons / body of persons etc. as loan, git or donation etc. (Enclose as per Schedule -9) Total --- x - fezc,78r Rs.) /f? 6. 78s - f0, 6, 7 %~.

4 ', FORM OF AFFDAVT - -." **~., ;- Be$ore the District Election Officer... <,".!/U.K)C~!.'?.?!;>...C~.<!.LS~...(District: StateNnion Territory) Affidavit of ~hril-.. J?&l... c..!..y.l,~~.?'~/y~c;.<.g.m...&.(i?.c~! d (S*, Wb+f~)... cl...l$.:.4.,... r.?..m.a... " 7'-,.,,... 4%-... c~l.+&~.&..&*<.o...., lr,/n...c<.cf.j...;,.-... s;rr.n...!?" So w~feldaughterof Solemnly and sincerely state and declare as under:- f ( hat was a contesting candidate at the general electionlhye election to the house of the pe ple /Legislative Assembly of.,~~.~<fi?.~..f~i.<fi.~.~.t?.~~'.. Par~lasseinhly constituency, the result of which wss declared on..!,<~l.s~.d C- - v (fi That my agent kept a separate and correct account of all expenditure incurred auu~orised by rnelrny eleciion agent in connection with the above election be&veen!d.:?:~~r~!:4..<~ (the date on which i was nominated) and the date of ihe result both days inclusive. 8 d hat the said account was maintained in the register furnished by the returning officer for urpose and thc said Register itself is annexed hereto with the supporting vouchers/bills ioned in the said account. the account of my election expendilure as annexed hereto includes all items of n expenditure incurred or authorised by me or by my election agent, the political pnrty sponsored me, other associationslhody of persons and other individuals supporting he election, and nothing has been concealed or withheld!suppressed therefrom (other he expense on travel of leaders' covered by Explanations and unser section 77 () Representation of the ~ullllllis~ont.r (Judli'a kel.d. No. ' < i?'' nqk., tt-' :',.,.- h.,,.,i:ee, CONGRESS canduate CE T:-..:^...~.~ r T l * P

5 4 '!? L (5) hat the Abstract Statement of Election Expenses as Annexure to the sard"i~;?&ullt a50 '' incjudes all the expenditure incurred or authorised by me, my election agent, the political pady which sponsored me, other associations/body of persons and other individuals supporting me, in connection with the election. il tl (6) That the statements in forgoing paragraphs () to (5) are true the best of my knowledge ang belief, that nothing is false and nothing material has been concealed.... at... this day of 0... before me. e and seal of the Attesting ion or Notary Public authority, i.e. Magistrate of the first Class or Oath

6 ,- -- r)7.yv] FPY 'ZSY ~.Lf'ff~ ;/ 06 +/ -aw POL sasuadxa slaqlo 7/ 6 m 7;)~ ~aub!edwe JelS 6u!pnpu! ~au6!edwm laqlo hue lo heuo!punj bed 'h!lqala '4las p sasuadxa 6u!6po[ 8 6u!p~eog 9 5 anua~ 04 luaa E sa6~eq ~ole~aua6 /uopdwnsuo~.~a~od (Aaub!edwe~ ~4s ueql Jaqlo laub!pdwe laqlo hue JO h!~qala 'jlas ~ o) sa6~eq~ j.jla saeoq /sap!qaa / yelye /lald0!lah 'yodsueq uo sasuadx] -'slauueg 'sla~dwed'sll!q pueq 'sialsod g -. A 'la S A~A~~UO~ 'vau!ldwe 'auoqdo!~ 'slayeads pnol 6u!l!~ s uaqlo hq pa~~n>u! 'UV aweu 4l!M b ed 'lod hq / paun~u!.juv lua6e alep!pu~ 4 "~J~V / pa~~n~u! 'lwy a~n~!puadx] p axnos.sa u! ON unowv le~ol a~nl!puadx] 40 alnle~.s aaep!pue~ $0 a~na!puadxa pue spuna suo!wla 40 sl!maa :6 oa T -salnpaqas

7 S. No 4 Date and Venue Name of the Star Carnpaigner(s) & Name of Party -- ",,,,,, Amount of Expenditure on public meeting Remarks, if any rally, procession etc. with the Star Campaigner(s) apportioned to the candidate (As other than for general party propaganda) in Rs. 4 /' <., L. /p Total Schedule- Details of expenditure on campaign materials, like handbills, pamphlets, posters, hoardings, banners, cut-outs, gates & rches, video and audio cassettes, CDsl DVDs, Loud speakers, amplifiers, digital TV/ board display, D display etc. for 5

8 au yueq aamelp 40 sllelap Q!M.aa.OU anbaq /aa ~ ~ u6tedue uo!pala aql 04 pasn pun4 UMO 40 ~unouvjo sl!elaa 0 d! sua6e A0?UW 'lod A0 'luw '" "ne s ~ a y ~.ON o ~ j b ~ sasuadxl 40 a~nle~ anuaa /pajjnju! a~n~puadx] 40 sa~nos,~ue ~0 SJ~~JOM u6!edu~ uo sasuadxl pue ale0 'S '

9 schedule- 8 Details of Lumo sum amount received from the mrtv (ies) in cash or cheaue or DD or by Account Transfer Name of the Political Party Date Cash DD/ Cheque no. etc. with details of drawee bank 4-5 Total Amount in Rs Total Schedule- 9 Details of Lump sum amount received from any person/company/flrm/assodations/body of persons etc. as loan, gift or!donation etc. S. Name and address Date (cash - 4 Total details of drawee bank,\ r L/ PC- gift or donation etc. 8 Note :. n Schedule 5:- (a) copy of the order containing list of all vehicles for which permit issued by the Returning Officer to be enclosed. (b) f the vehicle is owned by the candidate/his relativelagent are used for election purpose, notional cost of hire of all such vehicles, except one vehicle if owned and used by the candidate, notional cost of fuel and drivers salary for such vehicle, shall be included in total amount of expenditure in the above table.. n all schedules if any expenditure on goods and services, provided by the Political Party; or provided by any person/ company/ firm /associations/ body of persons etc. on behalf of the candidate, then the notional market value of such goods or services are to be indicated, in respective columns.. n Part -, the Lump-sum amount of fund received from the political party or others or the candidate's own funds, should be mentioned date wise. n all such cases such amounts are required to be first deposited in the bank account of the candidate, opened for election expenses. 4. Each page of the Abstract Statement should be signed by the candidate.