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Rs. 100
ONE
100 HUNDREnDIDECce

O01OO
kGINDIAINDIA
NDIA NON JUDICIAL Wwww
NSSION
f o fgT MANIPUR Form 265
(See rule 4A)
WEST

AFFIDAVIT TO BE FILED BY THE CANDIDATE ALONG HL

NOMINATION PAPER BEFORE THE RETURNING OFFICER FOR ELECTION
TO 12th MANIPUR LEGISLATIVE ASSEMBLY (NAME OF THE HOUSE)
FROM 30 LILONG ASSEMBLY CONSTITUENCY (NAME OF THE
CONSTITUENCY)
PART A
1, Syed Anwar Hussain**son of late Syed Umid Ali Aged 52 years, resident of Lilong
Haoreibi Sambrukhong, P.O. & P.s. Lilong, Distriet Thoubal,795130, Manipur, a

candidate at the above election, do hereby solemnly affirm and state on oath as under:-
(1)I am a candidate set up by Indian National Congress (L.N.C)

(2) My name is enrolled in 30/Lilong Assembly Constitueney, Manipur (Name of the

Constituency and the state), at Serial No. 914 in Part No. 30/2

(3) My contact telephone number(s) are +917085311555, +919366574465 and my social

media account(s) (if any) is/are

(i) Syed Anwar Hussain (Facebook)

wwwg.0301
KH. KHAMBA SINGH
Oath Commissioner (JUDICIAL)
Regd. No. 467 of 2021
Imphal West District, Manipur
 (4) Details of Permanent Account Number (PAN) and status of filing of Income tax
return:

SI.No. Names PAN The financial Total income

HE
OAM
CO

MIS IONER year for

which the
Shown in Income Tax Return
last(in Rupees)
Income-Taxinaneial Years
for the last five
completed (as
return has on 31 March)
been filed
IMPHAL
WEST

2021-2022 ) Rs. 1000/

1. Self AEEPH15 2020-2021 (ii) Nil
Syed Anwar Hussain 87H 2019-2020 (ii) Nil
2018-2019 (iv) Rs. 1357/-
2017-2018_ Rs, 22024/-
2021-2022 ) Nil
2. Spouse BUJPB961 2020-2021 ii) Nil
Zahanara Begum 9Q 2019-2020 (ii) Nil
2018-2019
2017-2018
iv)Nil
Nil
) Not Applicable
HUF (If Candidate isNot Not i) Not Applicable
Karta/Coparcener) Applicable Applicable ii) Not Applicable
iv) Not Applicable
v) Not Applicable
)NotApplicable
A. Dependent1 No PAN Not ii) Not Applicable
Syed Nihal Hussain
allotted Applicable (ii)Not Applicable
iv) Not Applicable
V Not Applicable
Not Applicable
Dependent2 No PAN Not i) Not Applicable
Lubnna allotted Applicable iii) Not Applicable
iv) Not Applicable
) Not Applicable
Dependent 3
Not Applicable
6. No PAN Not ii) Not Applicable
Zaibba allotted Applicable (i) Not Applicable
iv) Not Applicable
(v)NotApplicable

2
wwww e9020EA
KH.KHAMDA'SINGH
Oath Commissioner (JUDICIAL)
Regd. No. 467 of 2021
Imphal West District, Manipur
 for PAN holder to mention PAN and in case of no PAN, it should be
Note: It is mandatory
clearly stated "No PAN allotted".

(5) Pending eriminal cases

THE
OA
(OMMISS/2).) I declare that there is no pending criminal case against me. (Tick this
the Candidate and write NOT APPLICABLE
alternative if

there is no criminal case pending against

against alternative (ii) below) OR
* IMPHA
t wES
ii) The following eriminal cases are pending against me:
(If there are pending criminal cases against the candidate, then tick this alternative and

score off alternative (i) above, and give details of all pending cases in the Table below)

Table

(a) FIR No. with name

and address ofNot Applicable Not Not Applicable
Applicable
Police Station
concerned

(b) Case No. with Name Not Applicable Not Applicable Not Applicable
of the Court

(c) Section(s) of

concerned
Not Applicable Not Applicable Not Applicable
Acts/Codes involved

(give no. of the

Section, eg
Section...of IPC,

etc.).

3
w w . G9-0AU
1KHADA SINCH
Gain Commissioner (JUDICIAL)
Regd. No. 467 oi 2021
Imphal West District, Manlpur
 Brief description of Not Applicable Not Applicable Not Applicable
(d)
offence

Whether charges| Not Applicable Not Applicable Not Applicable

(e)

AISSiaN
COMMIS have been framed
HE
OAM

(mention YES or

NO)
1
If answer against (e) Not Applicable Not Applicable Not Applicable

I PHALN
WES above is YES, then
give the date on

which charges were

framed

(g) Whether any Not Applicable Not Applicable Not Applieable

Appeal/Application
for revision has been

filed against the

proceedings
(Mention YES or

NO)

(6) Cases of conviction

(i) I declare that I have not been convicted for any eriminal offence. (Tick this

alternative, if the candidate has not been convicted and write NOT APPLICABLE
against alternative (ii) below) OR

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

(If the candidate has been convicted, then tick this alternative and score off alternative
(i) above, and give details in the Table below)

4
Wwww9-02V
KH. KHAMDA SINGH
Oain Commissioner (JUDICIAL)
Regd. No. 467 of 2021
Imphal West District, Manipur
 Table

Not Applicable Not Applicable Not Applicable

(a) Case No.

Not Applicable Not Applicable Not Applicable

Name of the Court
(b)
Sections of Acts/Codes Not Applicable Not Applicable Not Applicable
AISSIORC
OAHCO

involved (give no. of the

Section.e.g.Section...
of IPC, etc.).
IMPHA
WESA

(d) Brief description of Not Applicable Not Applicable| Not Applicable

offence for which

convicted

Dates of orders of Not Applicable Not Applicable Not Applicable

conviction
Not Applicable Not Applicable Not Applicable
(f) Punishment imposed
Whether any Appeal Not Applicable Not Applicable Not Applicable
(g)
has been filed against
convictioon order

(Mention YES or No)

If answer to (g) above Not Applicable Not Applicable Not Applicable

(h)
is YES, give details and

present status of appeal

(6A) I have given full and up-to-date information to my political party about all pending
criminal cases against me and about all cases of conviction as given in paragraphs (5) and

(6). write NOT APPILICABLE

candidates to whom this Item is not applicable should clearly
IN VIEW OF ENTRIES IN 5(G) and 6(i), above]

Note:
1. Details should be entered clearly and legibly in BOLD letters.
columns against each
2. Details to be given separately for each case under different
item.

w wg 9 . 0 2 2 2

K. KHA:DA SINGH
Oalh CoTmissioner (JDICIAL)
Regd. No. 467 of 2021
Imphal West District, Manlpur
 3. Details should be given in reverse chronological order, i.e., the latest case to be
mentioned first and backwards in the order of dates for the other cases.
4. Additional sheet may be added if required.
5. Candidate is responsible for supplying all information in compliance of Hon'ble
Supreme Court's judgment in W. P (C) No. 536 of 2011.

I give here in below the details of the assets (movable and immovable etc.) of
COMMISSIThat
OAH
iyself, my spouse and all dependents:

Aetails ofmovable assets:

Note:1. Assets in joint name indicating he extent of joint ownership will also have to be
WESTN
given.
IMPHAL
Note: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.

Note:3. Value of Bonds/Share Debentures as per the current market in Stock

Exchange in respect of listed companies and as per books in case of non-listed
companies should be given.

Note: 4. Dependent' means parents, son(s), daughter(s) of the candidate or spouse and
any other person related to the eandidate whether by blood or marriage, who
have no separate means of income and who are dependent on the candidate for
their livelihood.

Note: 5.Details including amount is to be given separately in respect of each investment

Note: 6. Details should include the interest in or ownership of offshore assets.

Explanation,- For the purpose of this Form, the expression "offshore assets" includes,
details of all deposits or investments in Foreign banks and any other body or
institution abroad, and details of all assets and liabilities in foreign
countries';

6
w w w g q . 6 2 / 2

KH KHAMBA SINGH
Oain Cormmissioner (JUDICIAL)
Regd. No. 467 of 2021
Imphal West District, Manipur
 Self Spouse Dependent-1 Dependent-2 Dependent-3
S. No. Deseription
HUF

Rs.500/
O A HCQu

Oash in hand Rs.2,00,000/- Rs.3,00,000/- Not Rs.5000/- Rs. 1000/-

Applic
able
Bank.i)Axis Bank,Not Nil Nil Nil
Deails of deposit i)Axis
i n Bank accounts Thangal BazarThangal
applie
Term A/C No.Bazar A/Cable
FDRs,
MPHAL eposits and all 912010012566960 No.91201001
other types of , Balance- Nil. 2566960

deposits including Balance-Nil

saving accounts), i) Axis Bank
Deposits with Thangal Bazarii) Manipur
Financial A/C No.Rural
Institutions, Non-909010043455846 Bank,Lilong
Banking Financial Balance- Bazar A/C
Companiesa Rs. 10745.34/- No.90040120|
Cooperative 65205
societies and the iii) Axis Bank,Balance-
amount in each Kalyn Nagar,Rs. 2314/-
such deposit Bangalore
A/C
No.911010041047
118 Balance- Nil

iv) State Bank Of

India, Lilong
Branch
40770680137
Balance
Rs.10,000
Nil Not Nil Nil Nil
(iii) Details of Nil
investment in Applie
Bonds, Debentures able
/Shares and units
in
companies/Mutual
Funds and others
and the amount.

w.9.02
KH.KHAMOASINGH
Oztn Commissioner (JUDICIAL)
Regd. No. 467 of 2021
Imphal West District, Manipur
 Details of Nil Nil Not Nil Nil Nil
iv)
investment in NSS, Applic
Postal
Insurance
Saving
Policies
abe
OMMISS.and investment in
OAH Financial
yinstruments n

Phst office or

Insarance
anpany and the
áfount
Nil Nil Nil
sPHALPersonal Nil Nil Not
loans/advance Applie
given to any abe
person or entity
including firm,
company»
Trustete.and other
receivables from
debtors and the
amount.

Nil Nil Nil Nil

vi) Motor Vehicle/ Duster Car, Not
Aircrafts/ 03/2015, Applie
Yachts/Ships MNO1G-3786, abe
(Details of 17/12/2015,
Make,registraton Rs. 11,00,000/-
number etc. year
of purchase and
amount)

One ear ringNot Nil Nil Nil

(vii) Jewellery,bullion Nil
and valuable and one ringApplic
thing(s)
details of weight
(give weighing abe
about
and value) 10grams,
value of
Rs.49760/
appx.

www.ic9 02W
KH. KHAMBA SINGH
Oaln Commissioner (JUDICIAL)
No. 457 of 2021
Regd.
Manpur
Imphal West District,
 (vii) Any other assets Nil Nil Not Nil Nil Nil
such as value off Applic
claims/interest abe

Gross Totalvalue Rs.13,20,745.34/- |Rs. Rs.500/-

H E
0 A

Not Rs.5000/- Rs1000

3,52,074/- Applic
abe

IMDHALE S TME

B.Details of Immovable assets:

Note:1. Properties in joint ownership indicating the extent of joint ownership will also
have to be indicated

Note: 2. Each land or building or apartment should be mentioned separately in this

forma

Note: 3. Details should include the interest in or ownership of offshore assets.

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

HUF
Nil Nil Nil Nil Nil
(1) Agricultural Land Nil
Location(s)
Survey number(s)

Area(total Nil Nil Nil Nil Nil Nil

measurement in acres)

Whether in herited Nil Nil Nil Nil Nil Nil

property
(Yes or No)

Dateofpurchase in case Nil Nil Nil Nil Nil Nil

of self acquired
property

9
ww.a9 02 (O2
. KHAMBA `INCH
Oah Commissioner (JUDICIAL)
No. 467 of 2021
Regd.
Manipur
Imphal West District,
 Cost of Land (in case Nil
of purchase) at the
Nil Nil Nil Nil Nil

time of purchase

Any Investment on the Nil Nil Nil Nil Nil Nil

COMM and by wayof
HE
0A
@exelopment,
constructionete.
Approximate Current Nil Nil Nil Nil Nil Nil
matket value
(ii) Non-Agricultural Land Nil 8/Mantrip Nil Nil Nil Nil
AUWLocation(s) ukhri
Survey number(s)
256/part

Area(total Nil 3484 sq.ft. |Nil Nil Nil Nil

measurement in sq.ft.)

Whether inherited Nil No Nil Nil Nil Nil

property
(Yes or No)
Date of purchase incase of Nil 23-10-2019 Nil Nil Nil Nil
self-acquired property
Cost of Land (in case Nil Rs. Nil Nil Nil Nil
of purchase) at the 20,00,000/
time of purchase

Any Investment on the Nil Nil Nil Nil Nil Nil

land by way of
development,
construction etc.
Approximate Current Nil Rs. Nil Nil Nil Nil
market value 17,40,000/
(iii) Commercial Buildings i87A KhwaiNil Nil Nil Nil Nil
(including apartments) Bazar,xvi/500
-Location(s) /873
-Survey number(s) ii)King
Street,Lingar|
ajapura,
Kammanahal
li,Bangalore,
Survey No-
1249

10

www 9 0 3 . ?

.KHAMDA SINCH
Oath Commissioner (JUDICIAL)
Regd. No. 467 of 2021
Imphal West District, Manipur
 Area(total i)624.30sq.ft Nil Nil Nil Nil Nil
measurement in sq.ft.)
ii)1260 sq.ft.
Built-up Area (total i) 621 sq.ft. Nil Nil Nil Nil Nil
measurement in sq.ft.)
ii) 900 sq.ft
Whether inherited i) No Nil Nil Nil Nil Nil
1HE O MMISSroperty
041M
ii) No
or No)
Date of purchase incase of i)08-03-2021 Nil Nil Nil Nil Nil
sel-acquired property ii)04-08-2011

(incase of i)Rs.
of property Nil
IMPHAL WES
purchase)at the time of15,00,000/-
Nil Nil Nil Nil

purchase ii)Rs.
28,65,000/
Any Investment on the i)On Rent Nil Nil Nil Nil Nil
property by way of
development,
construction etc.
Approximate current i)Rs. Nil Nil Nil Nil Nil
market value 28,00,000/-
ii) Rs.
60,84,000
appx.
(iv) Residential Buildings 15- Haoreibi Nil Nil Nil Nil Nil
including apartments): 1207/A
-Location (s)
-Survey number(s)
Area(Total measurement7840.8sq.ft. Nil Nil Nil Nil Nil
in sq. ft)
sq.ft.)
Built up (Total 600 sq.ft.
Area Nil Nil Nil Nil Nil
measurement in sq. ft.)
Measurement in sq.ft.)

Whether inherited Yes Nil Nil Nil Nil Nil

property
(Yes or No)
Date of purchase Not Nil Nil Nil Nil Nil
incase of self Applicable
acquired property

11

Vww..9.02
2e2I

VH KHAMEA SINGH
Ceth Comnissioner (JUDICIAL)
Regd. No. 467 of 2021
Imphal West District, Manipur
 Cost of property(in Not Nil Nil Nil Nil Nil
case of purchase)at the Applicable
time of purchase
Investment the Not Nil Nil Nil Nil Nil
Any on

T HO
EA
CO MM/SSand by way of Applicable
dtevelopment,
construction etc.

|Rs. 45,000/- Nil Nil Nil Nil Nil

AaToximate current
aTket value

WAT Øthers(such as Nil Nil Nil Nil Nil

in
interest Nill
property)
vi) Total of current Rs. Rs. Nil Nil Nil Nil
market value 89,29,000/- 17,40,000/-
of(i)to(v)above

(8)1 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 before each item)

S.
No. Description Self Spouse HUF Dependent-1 Dependent-2 Dependent-
3
Loan or dues to Nil Nil Nil Nil
1) Nil Not
Bank/Financial Applicable
Institutionís)
Name of Bank or
Financial Institution,
Amount outstanding,
Nature of loan
Loan or dues to any Nil Nil Not Nil Nil Nil
other individuals/ Applicable
entity other than
mentioned above.
Name(s), Amount
outstanding, nature
of loan
Any other liability Nil Nil Not Nil Nil Nil
Applicable
Grand total o Nil Nil Not Nil Nil Nil
liabilities Applicable

12
ww.9.6 2 U2

KH. KHAMEA'SINGH

Octh Commissioner (JUDICIAL)

2021
Ragd. No. 467 of
Manipur
Imphal West District,
 ii) GovernnnentDues (A)Has the Deponent been n occupation of YES/NÓ
Dues accommodation provided by the Government at any (PI. tick
departments dealing time during the last ten years before the date of the
with Government
notilication of the current election ? appropri
accommodation
(B)If answer to (A) above is YES, the following ate
declaration may be furnished namely: alternati
() The address of the Government ve)

MIS IONE
OA/H COM
T H0
EA M
accommodation:
No due

******

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

Government accommodation, towards-
A1PH AL WIS (a) rent;
(b) electricity charges;
No due
No due
(c) water charges; and No due
(d) telephone charges as on .....(date) No due
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 Certificate' from the agencies
concerned in respect of rent, electricity eharges,
water charges and telephone charges for the
above Government accommodation should be
submitted.

V(ii) Dues to department

dealing with
Government transport Not Applicable N:L
(including airerafts and
helicopters)
Self Spouse HUF Dependent-1 Dependent-2 Dependent-
3

(iv) Income Tax dues Nil Nil Nil Nil Nil Nil

(V) GST dues Nil Nil Nil Nil Nil Nil

(vi) Municipal/Property Nil Nil Nil Nil Nil Nil

tax dues
(vii) Any other dues Nil Nil Nil Nil Nil Nil

(vii) Grand total of all Nil Nil Nil Nil Nil Nil
Government dues

13

www C9-022
4.KHAR5BA SINGH
Oalh Commissioner (JUDICIAL)
Regd. No. 467 of 2021
Imphal West Distnict, Manipur
 Whether any other Nil Nil Nil Nil Nil Nil
ix) liabilities are in
dispute, if so, mention
the amount involved
and the authority
before which it is
pending.

(9)Details of profession or occupation:

(a)Self: Contractor
(b)Spouse: House wife
(9A) Details of source(s) of income:
O f
T HO
E A ,

(OMMIS IO. (a)Self: Contractor Work

b)Spouse : Nil
e) Souree of income, if any, of dependents: Nil

S(9B) Contracts with appropriate Government and any public company or companies

IMPHAL STM
(a) details of contracts entered by the candidate: Nil

(b) details of contracts entered into by spouse : Nil

(c) details of contracts entered into by dependents: Nil1

(d) details of contracts entered into by Hindu Undivided Family or trust in which
the candidate or spouse or dependents have interest..Not Applicable..

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

spouse or dependents are partners: Nil

(f details of contracts, entered into by private companies in which candidate or

spouse or dependents have share: Nil

(10) My educational qualification is as under:

Bachelor of Arts from Mayai Lambi College Conducted by Manipur University in the
year 1992-93 under Roll No. 4117

(Give details of highest School/University education mentioning the full form of the
certificate/diploma/degree course, name of the School/College/University and the
year in which the course was completed.)

14
www O00.
KH. KHAMBA SINGH
Oath Cornnissioner (JUDICIAL)
Regd. No. 467 of 2021
Inphal West District, Manipur
 PART-B
ABSTRACT OF THE DETAILS GIVEN IN (1) T 0 (10) OF PART - A:
(11).

GTH
D E
A
(OMMISS/
1OName
Ng of the eandidate SYED ANWAR HUSSAIN

all postal address LILONG HAOREIBI SAMBRUKHONG, P.0. & P.S

LILONG, DISTRICT- THOUBAL, 795130
IA/B, WESNumber and name of the 30 LILONG ASSEMBLY CONSTITUENCY,MANIPUR
constituency and State
Name of the political party which INDIAN NATIONAL CONGRESS (INC)
set up the candidate (otherwise
write Independent")
Total number of pending eriminal NIL
cases

0. Total Number of cases in which NIL

convicted

7 PANof Year for which last Total Income Shown

Income Tax Return filed

(a)Candidate AEEPH1587H ) 2021-2022 i)1Rs.1000/-

2018-2019 ii)Rs. 1357/-
ii)
ii) 2017-2018 iii)Rs. 22024/-

bSpouse BUJPB96190 Nil Nil

c) HUF OT OT APPLICABLE NOT APPLICABLE
APPLICABLE
d) Dependent NOT NOT APPLICABLE NOT APPLICABLE
ALLOTTED
8. Details of Assets and Liabilities (including off shore assets) in rupees

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

A. Moveable AssetsRs. Rs. Nil Nil Nil Nil
(Total value) 11,00,000/-49760/-
B. Immovable Assets Rs. Rs. Nil Nil Nil Nil
8929000/- 1740000/-

w w w w n 9 0 2 I 2 K
15

i.KHAMDA SINGH
Oath Cornmissioner (JUDICIAL)
Regd.No. 467 of 2021
Imphal West District, Manipur
 Purchase Price of Rs. Rs. Nil Nil Nil Nil
self-acquired 4365000/- 37,40,000/
immovable
property
Development/cons Nil Nil Nil Nil Nil Nil
truction cost of
immovable
after
OA COMHA property
purchase (if
Pplicable)
IIIApproximate
Current
MAVIPYMarketPrice-
(a) Self-acquired Nil
assets
a)Rs. a)Rs. Nil Nil Nil
VEST
Value)
(Total4365000/- |17,000/-
(b) Inherited assets.
(Total Value) b)Rs.
45,000/-

9. Liabilities Nil Nil Nil Nil Nil Nil

i)| Government Nil Nil Nil Nil Nil Nil
dues(Total)
ii) Loans from Bank, Nil Nil Nil Nil Nil Nil
Financial
Institutions and
others (Total)

10. Liabilities that are under dispute

(G)Government Nil Nil Nil Nil Nil Nil
dues (Total)

(i)Loans from Nil Nil Nil Nil Nil Nil

Bank, Financial
Institutions and
others (Total)

11. Highest educational qualification:

Bachelor of Arts from Mayai Lambi College Conducted by Manipur University in the year
1992-93 under Roll No. 4117

(Give details of highest Schoo/University education mentioning the full form of the
certificate/ldiploma/degree course, name of the School/College/University and they earin
which he course was completed.)

ww ng.s2DA 16
KH.KHAFAËA SINGSH
Oath Commissioner (JUDICIAL)
of 2021
Regd. No. 467
District, Manipur
Imphal West
 VERIFICATION

1, the deponent, above named, do hereby verify and declare that the contents of this
affidavit are true and correet of the best of my knowledge and belief and no part of it is
i H0
E
COMM
4M

SIONE 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 5 and 6 of Part A and B above;

6 ) 1, my spouse, or my dependents do not have any asset or liability, other than those
mentioned in items 7 and 8 of Part A and items 8,9 and 10 of Part B above.
PHALWES
Verified at Imphal, this on the 9h" day of February 2022

DEPONENT

Note: 1. Affidavit should be filed latest by 3.00 PM on the last day of filing nominations.

Note: 2. Affidavit should be sworn before an Oath Commissioner or Magistrate of the

First Class or before a Notary Public.

Note: 3.Al columns should be filled up and no column to be left blank. If there is no
information to furnish in respect of any item, either "Nil" or "Not
applicable", as the case maybe, should be mentioned.

Note: 4.The affidavit should be either typed or written legibly and neatly.

Note: 5.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 O:ath Commissioner or
Magistrate before whom the Affidavit is sworn.

Solemnly affirm before me on

Bt...9..A:.. e Coyrt Premises 9-a2.2
www
hythe Deponcnt who is degiiiied by KH. KHAMEA GINGH
l,W ...hjk..kAM...e
Oalh Comnissioner (JUDICIAL)
Tie 2cit seens to
understand ihe|
o n tireir being read over| Regd.No. 467 of 2021
cont District, Manipur
and ex ImphalWest

17