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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:

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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

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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

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(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

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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

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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 :

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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)

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Details ofinvestment inBondsdebentures/ shareand units incompanies/mutuai

and othersamount.

NIL NIL NIL NIL

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NIL

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(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.

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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/

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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)

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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

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(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

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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

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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

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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

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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

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NOTAfTVtt

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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

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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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