Affidavit Format

Affidavit to be Furnished by the candidate alongwith Nomination Paper
Before the Returning Officer

For election to Bihar Legislative Assembly From 114, Taraiya
Assembly Constituency.
PART-A
I, Chandani Devi , wife of Late Ashok Singh Aged…………years, resident of, Charihara, Town/Vill-
Charihara, Anchal/Thana- Mashrak, Distt.- Saran, Bihar, a candidate at the above election, do hereby solemnly
affirm and state on oath as under:-
(1) I am contesting as an Independent candidate.
(2) My name is enrolled in the voter list of 115, Baniyapur Assembly Constituency, Bihar at Serial No………
in Part No……….
(3) Details of PAN and status of filing of Income tax return :
Sl. No. Names Permanent The financial year for Total income shown
Account Number which the last In Income
(PAN) Income-tax return has Tax Return ( in
been filed Rupees)
1. Self – Chandani Devi AOGPK6586B NIL NIL
2. Spouse- Late Ashok Singh NIL NIL NIL
3. Dependent 1- Aditya Vibhu NIL NIL NIL
4. Dependent 2- Jyoti Vibhu NIL NIL NIL
5. Dependent 3 NA NA NA NA
(4) The following case(s) is/ are pending against me in which cognizance has been taken by the court:-
Sl. Offence Description

No.
(a) The details of cases where the court has taken NA
cognizance, Sections of the Act and description of
the offence for which cognizance taken :
(b) Name of the court, Case No. and Date of order NA

taking cognizance :
(c) Details of Appeal (s) / Application(s) for revision NA

(if any) filed against the above order(s) :
4. Cases in which I have been convicted by a court of law(other those referred to in Form 26):
(a) The details of cases, Sections of the NA
Act and description of the offence for
which convicted :
(b) Name of the Court(s), Case No. and NA

Date(s) of order(s) :
(c) Punishment imposed : NA
1
(5) That I give herein below the details of the assets (movable and immovable etc.) of myself, my
spouse and all dependents:
A. Details of movable assets :

(Note:
1. Assets in joint name indicating the extent of joint ownership will also have to be given
2. In case of deposit/Investment, the details including Serial Number, Amount, Date of Deposit, the Scheme,
Name of Bank/ Institution and Branch are to be given
3. Value of Bonds/Share/Debentures as per the current market value in Stock Exchange in respect of listed
companies and as per books in case of non- listed companies should be given.
4. . Dependent`, here means a person, substantially dependent on the income of the candidate.
5. Details including amount is to be given separately in respect of each investment)
S. Description Self Spouse Dependent-1 Dependent-2 Dependent-3

No.
(i) Cash in hand
(ii) Details of Deposits in Bank

accounts (FDRs, Term Deposits
and all other types of Deposits
including saving accounts),
Deposits with Financial
Institutions, Non Banking
Financial Companies and
Cooperative societies and the
amount in each such deposit
(iii) Details of investment in Bonds,
Debentures/shares and units in
companies/Mutual Funds and
others and the amount.
(iv) Details of investment in NSS,
Postal Savings, Insurance Policies
and investment in any Financial
Instrument in Post office or
Insurance Company and the amount
(v) Personal loans/advance given to

any person or entity including
firm, Company, Trust etc. and
other receivables from debtors and
the amount.
(vi) Motor Vehicles/Aircrafts/
Yachts/Ships (details of Make,
Registration No. etc, Year of
Purchase and amount )
(vii) Jewelry, bullion and valuable thing
(give details of weight and value)
(viii) Any other assets such as value of

Claims/interest
(ix) Gross Total value
2
B. Details of Immovable assets:
(Note: 1. Properties in joint ownership indicating the extent of joint ownership will also have to be indicated
2 . Each land or building or apartment should be mentioned separately in this format.)
S. Description Self Spouse Dependent-1 Dependent-2 Dependent-3
No
(i) Agricultural Land
Location(s)
Survey number(s)
Area (Total measurement in acres)
Whether inherited property (Yes

or NO)
Date of purchase in case of self

acquired property
Cost of Land (in case of
purchase)at the time of purchase
Any Investment on the land by

way of development, construction
etc.
Approximate Current market value
(ii) Non-Agricultural Land

Location(s)
Survey number(s)
Area (Total measurement in sq.
ft.)
or NO)
acquired property
Cost of Land (in case of
purchase) at the time of purchase

etc.
(iii) Commercial Buildings

(including apartments)
-Location(s)
-Survey number(s)
Built up Area (Total measurement
in sq. ft.)
or NO)
3
acquired property
Cost of property (in case of
Any Investment on the property

by way of development,
construction etc.
(iv) Residential Buildings (including

apartments,)
-Location(s)
- Survey number(s)
Area (Total measurement in sq.
ft.)
Built up Area (Total measurement
in sq. ft.)
or NO)
acquired property
Cost of property (in case of

etc.
(v) Others (such as interest in

property)
(vi) Total of Current Market
Value of (i) to (v) above
(6) I give herein below the details of liabilities/ dues to public financial institutions and government :-
(Note: Please give separate details of name of Bank , institution, entity or individual and amount for each item)
S. Description Self Spouse(s) Dependent-1 Dependent-2 Dependent-3
No.
(i) Loan or dues to Bank/Financial

Institution(s)
Name of Bank or FI
Amount outstanding
Nature of loan
Loan or dues to any individuals/
Entity other than mentioned in
(i) above.
Name(s)
Amount outstanding
Nature of loan
4
Any other liability
Grand total of liabilities
(ii) Government Dues:

Dues to departments dealing with
government accommodation

supply of water

supply of electricity

supply of telephones/mobiles
Dues to departments dealing

with government transport
(including aircrafts and
helicopters)
Income Tax Dues
Wealth Tax Dues
Service Tax Dues
Municipal /Property Tax Dues
Sales Tax Dues
Any other dues
Grand total of all Govt. dues

(7) Details of profession or occupation:
a. Self………………
b. Spouse …………
(8) My educational qualification is as under:
(Give details of highest School / University education with full form of the certificate/ diploma/ degree course)
(Name of the School /College/ University and the year in which the course was completed.)
(9). ABSTRACT OF THE DETAILS GIVEN IN (1) TO (8) ABOVE:

1. Name of the candidate Sh./Smt./Kum.
2. Full postal address

3. Number and Name of the constituency and state
3. Name of the Political party which set up the

candidate (otherwise write ‘Independent’)
4. (a) Number of cases in which conviction order
passed (other than those referred to in Form 26)
5
(c) Total number of Pending cases where the court
(s) have taken cognizance
5. PAN of Year for which last Total Income Shown

Income Tax Return filed
(a) Candidate
(b) Spouse:
(c) Dependents
6. Details of Assets and Liabilities in rupees
Description Self Spouse Dependent-I Dependent-II Dependent-III
A. Moveable
Asset (Total value)
B. Immovable
Asset
(i) Purchase Price and
Development Cost of
Immovable Property
(Total Value)
(ii) Approximate Current
Market Price of
Asset (Total Value)
7 Liabilities
(i) Government
dues (Total)
(ii) Loans from Bank,
Financial Institutions and
others (Total)
8. Highest educational qualification:
(Give details of School / University education with full form of the certificate/ diploma/ degree
course) (Name of the School /College/ University and the year in which the course was completed.)
VERIFICATION
I, the deponent, above named, do hereby verify and declare that the contents of this affidavit are true and correct to the
best of my knowledge and belief, no part of it is false and nothing material has been 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 3 and 4 above; (b)
I, my spouse, or my dependents do not have any asset or liability, other than those mentioned in items 5 and 6 above.
Verified at…………………. …..this the……………………………day of………………………………. 201…………
DEPONENT
6
Note: 1. Affidavit should be filed latest by 3.00 PM on the last date of filing nominations.
2. Affidavit should be sworn before an Oath Commissioner or Magistrate of the First Class or before a Notary Public.
3. All columns should be filled up and no column to be left blank. If there is no information to furnish in respect ofany
item, either “Nil” or “Not applicable”, as the case may be, should be mentioned.
4. The affidavit should be either typed or written legibly and neatly.

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Affidavit to be Furnished by the candidate alongwith Nomination Paper

Before the Returning Officer

2. Spouse- Late Ashok Singh NIL NIL NIL

3. Dependent 1- Aditya Vibhu NIL NIL NIL

4. Dependent 2- Jyoti Vibhu NIL NIL NIL

Sl. Offence Description

(b) Name of the court, Case No. and Date of order NA

(c) Details of Appeal (s) / Application(s) for revision NA

(b) Name of the Court(s), Case No. and NA

A. Details of movable assets :

S. Description Self Spouse Dependent-1 Dependent-2 Dependent-3

(ii) Details of Deposits in Bank

(v) Personal loans/advance given to

(viii) Any other assets such as value of

Whether inherited property (Yes

Date of purchase in case of self

Any Investment on the land by

(ii) Non-Agricultural Land

Any Investment on the land by

(iii) Commercial Buildings

Any Investment on the property

(iv) Residential Buildings (including

Any Investment on the land by

(v) Others (such as interest in

(i) Loan or dues to Bank/Financial

Grand total of liabilities

(ii) Government Dues:

Dues to departments dealing with

Dues to departments dealing with

Dues to departments dealing with

Dues to departments dealing

Any other dues

Grand total of all Govt. dues

(9). ABSTRACT OF THE DETAILS GIVEN IN (1) TO (8) ABOVE:

2. Full postal address

3. Name of the Political party which set up the

5. PAN of Year for which last Total Income Shown

Verified at…………………. …..this the……………………………day of………………………………. 201…………

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