ABSTRACT STATEMENT OF ELECTION EXPENSES

PART - I

I Nameof the Candidate Sh./Smt.j Km. N~IL Mo_hd.·II Number and name of Constituency81 - P14~"",, .

III Nameof State/Union Territory HA R..ytfN~--IV Nature of Election

(Pleasemention whether General A-w=r~a1TElection to State Assembly / LokSabha/ Bye- election)

V Date of declaration of result 1,!-!c'ltt'-VI Nameand Addressof the Election A~ (\;toU, •Ag_ent

(J. p....,. P\4tJu.l'\~ .VII If candidate is set up by a political

party, Pleasemention the name of J~cle~the political partyVIII Whether the party is a recognised Yes/No-r="

political party

Annexure 15

Date:

Place:

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PART-II : ABSTRACT OF STATEMENT OF ELECTION EXPENDITURE OF CANDIDATE

I S. No. Particulars Amt. Amt. Amt. Total ElectionexpenditureIncurred Incurred/ Incurred/ Auth. by authorize / (3)+(4)+(5)Candidate d by Pol. authorize/ Election Party d byagent(in (in Rs.) othersRsj_ _{inRsl1 2 3 4 5 6I Expensesin public meeting, rally, procession

etc.:-1. a: Expensesin public meeting, rally, - - ,-....processionetc. (ie: other than the ones with ~

. Star Campaignersof the Political party_(Encloseas_Qer Schedule-U_1. b : Expenditure in public meeting rally,processionetc. with the Star Campaigner(s); - - .----- -(ie: other than those for general partypropaganda) (Encloseas per Schedule-2) •II Campaignmaterials other than those used inthe public meeting, rally, processionetc. 4~(fO - - 4~Ubmentioned in S.No. I above(Encioseas perSchedule-3)

III Campaign, through print and electronic mediaincluding cable network, bulk SMSor internet - - ~ ~and Social medialEnciose as per Schedule-4),

IV Expenditure on campaign vehicle(s), used by \O~3S - - \~3~Sscandidate(Encioseas per schedule-S)V Expensesof campaign workers / agents - - - -(Encloseas_QerSchedule -6)VI Any other carnpaiqn expenditure ~.. ~~IS- - - \ 3_ClISGrandTotal Jdt'l(Xb _l.~"'E\~~.

PART III : ABSTRACT OF SOURCE OF FUNDS RAISED BY CANDIDATES No Particulars Amount_{inRs.)1 2

3---r Amount of own fund used for the election campaign

lo,<rtfb(Encloseas per Schedule - 71II Lump sum amount received from the party (ies) in cashor cheque etc. -(Encloseas per Schedule -IllIII Lumpsum amount received from any person/ company/ firm/ associations/ body of

118crmpersonsetc. as loan, gift or donation etc.(Encloseas per Schedule -9)Total

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, ~ pt)'1 ~ \'PART- IV VII ~___., ~

". FORMOF AFFIDAVn '. ~~]/ .1Before the District Election Officer ·· ·..···· (District, St~o~~bryr- ••~." " ~

~ (lhlro)Affidavit of Shri/Smt/Ms Nrr:tfY..M{:)A.d ..< ~, W/o,D/o) .s.~r.t:lt.&................. I son/wife/daughter of.............................., aged .'t.o.... years, rio ..«,~d..IJt ?re... do herebysolemnly and sincerely state and declare as under:-

r;:i;~~~~::.~~yn~stin~f9~:l!:.~~l?I.~I~~iO~/~~~~I~~i~~.t~.t.h~.~~~~.~.~f..th.~.".~~:.leI............. Parliamentary/ Assembly constituency, the result of which was declared on....7'.-1f)-/-·..,·J.·(2) That limy election agent kept a separate and correct account of all expenditure incurred /authorised by me / my election agent in connection with the above election between ..(the date on which I was nominated) and the date of declaration of the result th~reof, both daysinclusive.

• (,\,'~S/o~3) That the said account was maintained in the Register furnished by the Returning Officer for the~(:/ cV" ~o~e and the said Register itself is annexed hereto with the Supporting vouchers/bills mentioned in;;of ",' • t ~Id account.o tv . f

• ~That the account of my election expenditure as annexed hereto includes all items of electionX'penditure incurred or authorised by me or by my election agent, the political party which sponsored

- me, other associations / body of persons and other individuals supporting me, in connection with theelection, and nothing has been concealed or withheld/suppressed therefrom (other than the expense ontravel of leaders' covered by Explanations 1 and 2 under section 77 (1) of the Representation of thePeopleAct, 1951).

(5) That the Abstract Statement of Election Expensesannexed as Annexure II to the said account alsoincludes all expenditure incurred or authorised by me, my election agent, the political party whichsponsoredme, other associations / body of persons and other individuals supporting me, in connectionwith the election.

(6) That the statements in the foregoing paragraphs (1) to (5) are true to the best of my knowledgeand belief, that nothing is false and nothing material has been concealed.

~ent

Solemnly affirmed/sworn by at this day of 201 before me.

(Signature and seal of the Attesting authority, i.e. Magistrate of the first lassor OathCommisSionor Notary Public)

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Schedules- 1 to 9: Details of Elections Fundsand Expenditure of CandidateSchedule- 1

Expensesin public meeting, rally, processionetc. (ie: other than those with Star Campaignersof the Politicalparty)S. Nature of Expenditure

Total Amount Sourceof ExpenditureNoin Rs.

Amt. incurred! Amt. Amt. incurredAuth. by incurred! by othersCandidate! by Pol.agent Party with

name1 23 4 5 6

.L1 Vehiclesfor transporting visitors >"

/2 ErectingStage, Pandal& Furniture, Fixtures, • Vpolesetc.3 Arches& Barricadesetc.

/4 Flowers! garlandsL5 Hiring Loud speakers, Microphone, amplifiers, dcomparersetc.

6 Posters,hand bills, pamphlets, Banners,Cut- J~outs, hoardings7 Beverageslike tea, Water, cold drink, juice etc. L8 Digital TV -boards display, Projector display, .... jtickers boards, 3D display9 Expenseson celebrities, payment to musicians, /other artists remuneration etc.10 Illumination items like serial lights, boardsetc. /111 Expenseson transport, Helicopter! aircraft ! /vehicles! boats etc. charges ( for self, celebrity

or any other campaigner other than StarCampaigner)

12 Powerconsumption! generator charges /13 Rent for venue j14 Guards& security charges15 Boarding& lodging expenses~f self, celebrity;

party functionary or any other campaignerincludingStar Campaigner

16 Others expensesTotal

Schedule- 2

Expenditure in public meeting rally.,processionetc. with the Star campaigner(s) as apportioned to canGlidate(ie: otherthan those for general party propaganda)

S. No Date and Name of the StarAmount of Expenditure on public meeting Remarks, if anyVenue Campaigner(s) & Name of Party rally, procession etc. with the StarCampaigner(s) apportioned to the candidate(As . other than for general partypropaganda) in Rs.

,.-"1 2 3 4 .> 51 .>2t-~V3 .>4 -:

--Total

Schedule-3

Details of expenditure on campaign materials, like handbills, pamphlets, posters, hoardings, banners, cut-outs, gates &arches, video and audio cassettes, CDsl DVDs, Loud speakers, amplifiers, digital TVI board display, 3 D display etc. forcandidate's election campaign ( ie: other than those covered in Schedule- 1 & 2)S. Nature of Expenses Total Amount Sources of Expenditure

Remarks, if anyNo. in Rs.Amt. By Amt. By Pol. Amt. By otherscandidate I Partyagent

1 2 3 4 5 6 71 l~~ lf~O"\) t\ ~Cf\) - .-- - .. ,'.-2iJI' .•3

4

Total ~O'O 1l~1YOSchedule- 4

---Details of expenditure on campaign through print and electronic media including cable network, bulk SMSor internet orsocial media etc. for candidateS. Nature of Name and address Name and address of Total Amount Sources of ExpenditureNo medium of media provider agency, reporter, stringer, in Rs.(electronic I (print /electronk company or any person to Amt. By Amt. By Amt. Byprint) and Isms I voicel cable whom charges I candidatel Pol. othersduration TV, SOCialmedia commission etc. paidl agent Partyetc.) payable, if any Col. (3) +(4)1 2 3

,4 5 6 7 81

~ !----2~

~\V3 -:v

-4,

Total

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1 1Schedule -5

Detailsof expenditure on campaign vehlde (s) and poll expenditu", on vehicle(s) for candidate's election campaignS. Regn.No. of Hiring Chargesof vehicle No. of Total amt. Sourceof ExpenditureNo Vehicle&

Daysfor incurred/Type ofRate for Fuel charges Driver's which auth. in Rs.

Amt. By Amt. By Pol. Amt.Vehicle

Hiring of (If not charges usedcandidate/ Party Byvehicle / covered (If notagent othermaintenan under hiring) covered

sce underhiring)

1 2 3a 3b 3c 4 5 6 7 81 "~~g&l~'fe :.s9~(1'\) - ~Clt> 11~ ~110\) y-::j1~ - -2 K5-~A~"'~ .:s~ ,..- 'lSC'l) 'S():~ ~ro Lt3S(1) - --3 II'\.r l1-l~ I~ mS .- ~ SD~ 'l~ ,~~ - ~4 '1","Sl-S~ ~qO'\) IcrlfO ~UJ('l y~vo lla IYt') - --Total ~135 l'-DlfO _ ,~s- \~3~3S--

-~----Schedule- 6

Detailsof expenditure on Campaignworkers / agentsS. Date and Expenseson Campaignworkers Total amt. Sourcesof ExpenditureNo Venue

Nature of Expenses Qty. No. Of workers incurred/Amt. By Amt. By Pol. Amt. By""agents auth. In Rs.candidate/ Party othersagent1 2 3a 3b 3c 6 7 8 91 Campaignworkers ,------honorarium/ salary

etc.~2 Boarding

~~ --

3 Lodging4 Others .....

Total

Schedule- 7

-Detailsof Amount of own fund u!ed for the election campaignS. No. Date Cash DD/ Chequeno. etc. with Total Amount in Remarksdetails of drawee bank Rs.1 2 3 4 5 61

2

.- -3 ,4

~9

Total

Schedule- 8

Details of Lump sum amount received from the party (ies) in cash or cheque or DD or by Account TransferS. Name of the Political Party Date Cash DD/ Cheque no. etc. Total Amount Remarks, ifNo. with details of drawee in Rs. any

bank1 2 3 4 5 6 71

2

3

4 ..Total

I •Schedule- 9

Details of Lump sum amount received from any person/company/firm/associations/body of persons etc. as loan, :Jift ordonation etc.

S. Name and address Date Cash DD/ Cheque Mention Total Amount RemarksNo. no. etc. with whether loan, in Rs.details of gift ordrawee bank donation etc.

1 2 3 4 5 6 7 81 j.~boj ~IOJY)~' 1~1'~t~,t (iLl, - - ~~I~'""~""',2 wonldR~~i~ t5'\\tllll)'I+ ~ - - '~m"'o-o-3 IPnbI''Il ~~~ .-{\s- ~- - - ao,O'$",-o.o4 ~d ""'''''F ~ .------4- .- ~,G\I'b """'\)..,.19 TotalJclh'd - f<A- ~ - ai, \lG V ~"1)

0, (!lfO""iJ

Note:1. In Schedule 5:-(a) copy of the order containfng list of all vehicles for which permit issued by the Returning Officer to beenclosed.

(b) If the vehicle is owned by the candidate/his relative/agent are used for election purpose, notionalcost of hire of all such vehicles, except one vehicle if owned and used by the candidate, notional cost offuel and drivers salary for such vehicle, shall be included in total amount of expenditure in the abovetable. ;2. In all schedules if any expenditure on goods and services, provided by the Political Party; or providedby any person/ company/ firm /associations/ body of persons etc. on beha If of the candidate, then thenotional market value of such goods or services are to be indicated, in respective columns.3. In Part -III, the Lump-sum amount of fund received from the political party or others or thecandidate's own funds, should be mentioned date wise. In all such cases such amounts are required tobe 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.

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