..

'. .. -- . '. "_;aiiUiilUt.rl~ u hUiiiHiuiAi LicW..TNtI. SCORE. PA NA 00000

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2491

FORl'vi 26(See rule 4/\)

~ - . ~'-

o Affidavit t.be filed by the eaadidate itl•• gwith DGIIlin.ti". D'p<r before therem-in ffi , .. J t' l 6(HAR. LE4ISL.A7,vG c.oU6'{e.n f b H ). • g 0 leer lor e ee ron ,0 •.••.••y \ll!;;me 0 t e owef:romf.W:t~B••hfrt!gAlIXf...~~.~fo'rlf'JrueDcy(Name of the Cvu~ dnuucy)

PART-A. tv{OI1SIN Af)

J.~y~~.~!1~~.~~.IP..t:1.~."!~.~~ "sonlda~cr/wne of $.'Y.6.1?.. r:'.~.S.I.~.~.~.'~..::;~ ..::"NAU>rN bA BollOIAged <9.R years, resident of~~.t:'~~.:-.t.1!~~~,.~ ..~:.~!~~~~.R~h1enbon tuUpostal address}, a candIdate at the above election, do hereby solemnly affirm and stateon oath as under.. .

~A$H,RIYA. . . . :rPrN A '1' "'DA-l- . . ., .

(1) I am a candidate set up by (.. name bf t.~<;kV;;(J'~:~.! pj..rry)J.~-;Qnt~stiflgas sa IflclepeneiefiteztnaidBk. .("strike out whichever is not applicable)

(2) My name is enrolled in.n~::··~;t:t.~~~I:'.I3!.r,..(~.~.~.~~~.~)&ta.~~fthecor.L.:tituencyand the State), at Serial Nof:~':l.inPart No.~.~.~

(3) My contact telephone number(s) isLpee 0~:~..~.~.~~.~.~I and my email

. . MCI)SHI RAZ i (1R£b/FPfVfPrfL'C;OM. 1'/ .. ; n •ID (If any) IS ~ and my social media aCCOur.\,~) (if any) Is/are

(i) N9 '" '" · (ii) N.~ (iii) ":-!9 .

(4) Details of Perm~ount Number (PAN) and starns of filing of Income Taxreturn: 7--'-- ..~~l SI.

No.r

I1

Names PAN The financial year) Tota! income Jfor which the 12.St i sho'Wll inIncome-tax return r Income-taxI has been fibJ· I retW1l (in

'N A-O i Rupees)I-:---+-::~;-------l?~~=-- __ +- _. .__.. __.. ! __'~I.__ -+~S~d~tl~~~e~rD~~~H~U~~H~I~_~_·_H-F~~~~~P~M~~~g~~~~~+-N~O~ ~,__~N~A ~2. I ~use _(sH A1-IL.A IQi!IESttrill . NO _N f) N A

D~ndenl-I NA N A "fA..,) ..

4. D~ndent-2 l-JA NA tV A5. D~ndent-3....... J'iA NA ,NA

.'

~)r

if the dcr-v-cnt is accused of any such offenceis) he shall furnish the followinginfonnntinn:- NA(1)The following case (3) is/are pending against me in which charges have been framedb the court for an offence unishable with im .sonrnent for two ears or more.-

NA

(a) Case/First Information ReportI NoJNns, together withI I complete details of concernedI ' P01iu~,~tation/DistricVState,rbfrsl;~;llC'::C;;)--;:X--ihc concernedI I A(;i(,) '1nd sbort description: of the oITcnce(s) for which

char cd~~~--~~~--~------~----------------------~(c) Name of the Court, Case No.and date of order takingco . ce:

NA

NA '

r

NA(d) Court(s) which framed the

ely c s) NAateis) on which the

NA

(ii)The following case+s) is/are pending against me in which cognizance has been takenby the court [other than the cases mentioned in item (i) above]»

'(a) ~XJn;l~~(;tl!'l~'Co~rt,Case Nd';and chie of order takingcognizance:

- --.-.---------. --INA

_ I

(b) The details of cases where thecourt has taken cognizance,section/s) of the Ac:t(s) anddescription of the offence(s)for which cognizance taken

NA

(c) Details ofAppeaJ( s)/ Appl ication( s) for

IIC'Vi.'li";> (if any) filed against

j , the above order(s)NA.

(6) I have ~/have not been convicted (If an offencets) [other than any offence(s)referred to in sub-section (1) or sub-section (2), or covered in sub-section (3), of section8 of the Representation of the People Act, 195] (43 of 1951)J and sentenced toimprisonment for one year or more. "

If the deponent is convicted and punished as aforesaid, he shall furnish the followinginformation: N A

In the following cases, 1 have been convicted and sentenced to imprisonment by acourtof law: _--,,-,-.,-. -,

~::::s:==tI~':__:':'::___ details of c~c::::s::!.,-L1 .!...N..L.!:A1 ---.J

,

.., , ~~)J ~~

IT:~r:'~';I);(S) of the concerned1 ! Act(s) and description of the --~(f",,(,) [0< which NA

onvictedarne of the Counts), Case

NAI I No. and daters) oforder(s):rLUun"~m'nt irnroscd NAd) i \\'~r;n1er any appeal was/has

1 k~ ~ fi led against the! cr'~' ';ction order. If so, details NALL,ncr now, present statusof the~r:-:;',I: ..

(7) That I give herein below the details of the assets (movable and immovable etc.) of'myself, my spouse and all dependents:

A. Details or movable a!sets!

Note: 1. I,.ssets in joint name indicating th,e extent of joint ownership will also have to be

ote: 2. In case of deposit/Investment, the details including Serial Number, Amount, date, of deposit. the scheme, Name of the Bank/Institution and Branch are to be given: pt1ltc:3, V.alue of Bond~Share Dcb~tures as per current r:narketvalue in .Stock exchange

\'\,. In respect of listed compemes Hid as per books Incase of non-listed compenies"~ should be given. .

~" ~ ote:4. Dependent here has the same meaning as assigned in Explanation (v) underC \_ section 75A of the Representation of the People Act, 1951.NNr: 5. Details including amount is to be given separately in respect of each investment

l:

(it)

S1.No.

Dependent-I Dependent-Z Dependent-SSelf Spouse

(1) Cash in hand I?.Ot:>D/ 6t;oOj- NA NADetails of deposit in II.. 1"''''~ "..,.,.- '7')Bank accounts/Ffrks,Term Deposits and all (P ~other types of deposits 10f \Jl" t _~including saving I~~ / ~~ ~accounts). DepOSits~' ~ Y'with financial ~ \I?~lnstirutionr. Non- ¥' ,Banking FinancialCompanies andCooperative socienesand the amount in

I-- ~~ch su~d~~_si_I I--_ ---+---7:-=:-+--------+------t-------1(iii) Details of investment ....

NA NA

In Bonds,debenturcst.uarcs and NA NANA NA NAunits

.~,lutu.al

r

r!

I

I

~_l\{ \ t?; I \}\\ V,

I ,__ .,_r--T-;:-- <--others and L/' \ I ,

\: , v ,

II I ,'.~-'-- ,-,I~t-~r~~'-,;' - r--;-';::;""'men'

1! • "- .......t s tJ: L

I .- '. :.('c - 11" '! I.. ' '. - ost." u3vmg,hc.;,.".v~-r>t"I);ci"s and• - ~ -' _,}. ",' " • ~1.,.-

!I i~''ro!;", rmc r- + in aJ1Y -, I1• ~ \",•.._);'.1 j " • I • l

NA iI C' '"I instruments NA NA NA NA I' ma.'1Ck,in Post office or ,IInsurancr- Companyand the "--"nnl- -'-- ----;- r-'(v) I'r,":.",,-" ' loons/Rr'-·---- ,-,\...:,:~ tn any

I f*:r:'-" .'! '-'r entity rinclll'~lnr' firm, 1comp:1,n:', Trust etc., NA NA NA f'JA NI\and other receivablesfrom debtors and theamount

I (V1) ~fN(.'~ Vehicles/ I HlVt 2.;004 IAircT~)f,::; :chts/Ships(D(',t~;)." .. r Make, BR /")(-llIgrcgir'""' c·' n!Jrnber NA '. -- N A 1'--' A NAetc, ye:)~ - , purchase Z,3lt,Qoo/-and nmourSJ

(vii) Jewellery, bullion and J~;~OD~olvaluable thing(s) (give r<i~o r NAdetails of weight and~~

N A N A==8 ~2..0gS0Tvalu~ %,'4,1,Gl) "~,t1 'Y'sOJ-(viii) Any other ?ssets such 2 Ncf.>. ~

I Ias " , ..~of iDI?>8;1f, NA NA N A- NAclaims/> , ". 11-1 J" So 1t llll.O..D.c.... ,.

_{ixl Gross ; ~...~ ~ ~;,~ : ~ 1(" .15Q1-_411..1- lI,sq 8~31-! NA I\fA 1 NA-_.,_ ._, ~..- ---_.-

.i->::

~~\VJ

B. D<:t~ilsof immovable Assetsj r

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

,Note: 2. EP,r1- 'and or building or apartment should be mentioned separately in this

f(,----

. ,;

s. Descrir! Self Spouse Dependent-l Dependent-2 Dependent-SNo. ....._(i) Agricultural Land k:~, "",.,,,

Location(s) ~ft,t NO''\1i NO NA NA NASurv~ numben s) I!>IHft-~SH~IF'

Area (total:2 . 5 A()"L.!. j NO 1 NA NA: N'Ameasurement inacres)

Whether :'lherited '('€S ~O NA NA f\lA~ - ...-.....,-------_.

, ,

I ~f!..!:"'...D 10 '" Z zCI:o.c- :00 x- 0 0V"l 1\iJ ~lQf ~

:u

lZ 12 z. L: ~')' ; 0 Q 0

<- ~ Z z; ~£0 0 0 0r-~l-00,

~2 Z Z. Zo_ a 0 0

z z. z Z»» 1:> »

--r------r-Z Z Z Z1::> » 1:>J>

---<f

(;~J-_._ ..__ .. -----\, ..1

~"\ ~'~\ v\Y \ '~Any investment on the ~ \. ~ J

property by way of '60,ODDI-development.

~t-JO NA NA ND.

construction etc.Approximate current 3',56,2-5°1 N~ Tmarket value NO NA NA ;

(iv) B~Qentii!l :ayil~inK!i ~~ No-ill 'I'jlSgfioi, I

(including Pf.et- Nc ·11J. r:LIH NC-IDr,apartments ): ~~~.1(J8 ~ HPrN'f1 V ft1.I-Location(s) ~~1M~N" NA N~ NA-Survey number{s) &1HAR..5HA-RIF Pllr1NA

80()O"l-O ...Area (totalmeasurement in sg.ft.) 20415 blO NI\ N~ NABuilt up area (Total

·~SOO If 90 Nil. NAmeasurement in sq.ft.) NAWhether- inherited' '{ES""V~"] (Yes or No) N.O NA NA NI\

i Date of purchase in-,

case of self-acquired N~ q I~1,0, €P, NA NA_1Il~l"'Hl NACost of property (incase of purchase> at. t--IA tl, bo, ooo/- ~PI NA NAthe time of purchase .Any investment on theland by way of

30,()OO /-development, NA NA ~f\ NAconstruction .etc.Approximate current

t~l,BI,2.5DI I-JA NA !market value 1>0,00,000/- kiP.·w··

(v) Others (such asinterest in~perty) NA Nil< NA' N~ NA

(vi) Total of current marketg,~;&'.f/5()e 30,00,000/- NAvalue of(i} to (v) above NA. NA --

(8) J give herein below the details of liabilities/dues to publ-ic financial institutions andgovernment:-

(Note: please give separate details of name of bank, institution, entity or individual andamount before each item)

S. Description Self Spouse Dependent-I Dependent-2 Depeodent-3No.(i) Loan or dues to

Bank/financialinstitution(s)Name of the Bank or No No NA NA NAfinancial Institution,Amount outstanding,

_..._.J

-..-._

~ -::::~ '_""

..::;~ if§ s-e:~~ ~oJ ~ o--J~ U.Ii r ~w~ g: 0 ~Q.~

!!.~~ l~~ §OQ a.~o ~R~.....0 z g. 0 .-. 0 b

;:J O'O-~{j g.r:r ;g[ ~§. ~. .::w < fi~! o f! 0 0-= s-:::ls-n. "'s:. ~ [~~ &' ~ g~.a f.~'~~ s,t.: § ~ S·ll I ~ItS<o&:n~5' (3 '8 fa ~

§ ... 0 ~Ii a

~ OQ 0~. 0. 0 goo ....:::,..,P.6 ('D C. ('D ET

0<:) r::. ft (;;' fa. 0

:roW ~.., ('D ~.J ~ W i ~L~(9 0 :J ~ 0R·~.0 s, 0 a 5-~ §_ ..~('D§::+; n 0 ..,

~ , o 9 ('D ...2: ~~ § ag_ 0- 0..0.. t'2. ... n. gETc. S-o.. Erf; ~,.. A-11

~!?O ~. §-~ fi 0- 0-

~H 1 o 1a.ii,j'

:3 g ~

(l ~.

§-~ fi g o til n

is::T ~ S' g ~ '<

jg"'tl s:11 0 J fA2:ij )

i~l:I a::

~ f ~ g.$'g.<!('D

~ ...-. 0:; 0 ...,

ii"'2, s. g ,. 0

~gzc, ET"',<

o 0~ ~ '8 S. () o g 6ft -e n

05 [ ~

(G'-<' S. g s~::t ET g o 1:1 ETr;;- 0....... .....- ~ ..... .... ..... ....z z.

~ ~z; z;

~ 'Z Z Z z 7__ z z ~ Za c:;:l c () 0 0 0 0 0 0 0 0

__:__'="'_

~ ~,~; I)'

zI~-.<:: 2 z a z z ;

I z z' z z < z lz0 2

00 cs 0 o. 0 I c (::) 0 0 0 0

0

-_,z z z z ~z z z z Z z

~ Z Z Z _z)::' ::P ::l> :p )::>l> Z.

;l'" _!po p p »_» 'l> j::>

. .J:>

Z z:2 z z.2.I~ z z z z z z ; Z:l> Z. :p )::> :J> l" ~ )::>

):> ~ ~ J:> _:p ~ ~»

l__:__ \

Z 2 Z. Z. z :z.~z Z z z Z z z z z

~ l> 'j:I l> .D 1> ::t> J;. » ;p ):>

:> l> '» »

@I---1

(a) Self .. .fAlZM§.~...~.~.?~.~ ~.?~~~.~(b) Spouse HI?Q.,$.~.~!.f:.~ : .

(9A) Details of sourcets) of income: .' - _ ~() S If °ENTt\-L + f>t4l\lcULTUI{b ,.~ c\a e ... .1:1..................... ~ ..' ~\I'")...\'1\\\,'"

(b) Spouse ...... t::I.o. .t>:'.?.. ... ..... .,.,V' .~~ V \ v \ \

(10) My educational qualification is as under.- M L)!'l'V~ RSI TY (_1Ci 1-2').~A..~ ..Mll\hA ..~~M:'.~..~.w.~~~;..~.~I?-.I, ... I\~M)I-\ ,(Give details of highest School/University education mentioning the full form of thecertificate/diploma/degree course, name of the School/College/University and the year inwhich the course was completed.) ,_

rPART-B

(ll)ABSTRACTOF THE DETAILS GNEN IN (1) TO (10) OF PART-A;i _-I: : ,;:; ..

1.2.3.

Name of the candidateFull postal address -Number and name of the constituencyand State

4. Name of the political partywhich set upthe candidate (otherwise write'!n4ependentl

5. (i) Total number of pending caseswhere charges have been framed by theCourt for offences punishable withimprisonment for two years or more

NO

(ii) Total number of pending caseswhere the court(s) have takencognizance [other than the casesmentioned in item_(i) abov~

NO

6 Total Number of cases in whichconvicted and sentenced toimprisonment for one year or more[except for offences referred to in sub-

. sections (1), (2) or (3} ox section 8 of: : Representation of the People Act,

1951).

NO!i

7. PAN of Year for which last Total mcome shownincome Tax returnfiled~~~~-----+~~--~~~~~~~-------+------------,--j_a) Candidate AH tv\. P M "l4_8 ~.:r NO Np.,

ib)Spouse NA -t---N-:-A----t--.....;N~A-----119.D~ndents .NO-··_.!. N to., N A

8,"",_::;~_~ Details of Assets and Liabilities in Rll£ees

.~dent-m

r

IIA. ! Moveable Assets 5,0141;; IIIS'l,SG,3 NA 'NA NAJTotal val~B. Immovable Assets _ .

I. Purchase Price ofself-acquired

ND l,bO,OOD/- t--JA NA NAimmovable.... v..,._ .. _

n. Development!construction costof immovable ND 30,000/- ~

NA.-property after NA NA

purchase (ifapplicable)

III. ApproximateCurrent marketprice-

-r-(a) self-acquired C"') NA ,,(1.) "fA NA- NA Iassets (TotalOO,DO,tJOf>/-Value) .

(b) inherited b) J,) NOr::-assets (Total ~,~,~1Value) 5®_t

9. Liabilities(i) Government dues ND NO NA NA NA(Total)(ii) Loans from Bank. IFinancial

NO N~ Np, NAInstitutions and NOothersJIotaI) -

10. Liabilities that are under dispute(i) Government dues

NO NA NA ,. NA(Total) NO"(ii) Loans from Bank,

FinancialNO No NA NAInstitutions and NA

others_(Total] . . J111.

Highest educational qualification: S.Ar.~F'<t _./~li~ '11:oJ:::i M.. ~IJ •

(Give details of highest SchoollUniv ity educa Ion mentioning . fo of the

I certificate/diploma/degree course, name of the SchooJ/CcIIegelUniversitY and the yeary (/tt?!in which the course was com~eted.) I

VERlJilCATJON

(b) I, my spouse, or my dependents do not have any asset or liability. other thanthose mentioned in items 7 and 8 of Part A and items 8, 9 and 10 of Part Babove.

~~t. Affidavit should be filed latest by 3.00 PM on the last day of filing nominations./ole: 2. Affidavit should be sworn before anOath Commissioner or Magistrate of the

First Class or before a Notary Public.e: 3. All column should be filled tip and no column to be left blank. If there is no

.......x' infoItD.'ition to furnish in respect of any item, either "Nil" or "Not applicable", T:\ - \ as the case may be, should be mentioned,

\ <'"d). Note: 4. The Affidavit should be either typed or written legibly and neatly.

Li ii

-r-

<;., \

0(;'(

-._

1.

2.

" '1

NameSyed Khurshid Mohammad Mohsin

Shahla Khurshid (Spouse)

ANNEXURE A

Particulars AmountRs. 61,082.00/-

(As on 05/04/2018)

I.Central Bank of India

Alc No.-1485580977

Bain House, Biharsharif

Branch Code-12

2. State Bank of India Rs. 2,23840/-

(As on 08/04/2018)Alc.No.30007945170

PBB Doctor's Colony

H-29, Kankarbagh, Patna- 20

Branch Code- 4445

1.UCO Bank

Alc No.- 15570110044711

Rs.32,113.14/-

(As on 05/04/2018)

Kankarbagh, Patna- 800016

00000

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fl~~-<i~~ 37527C BtH~R ~INDiA "*ZEm*Z!'!m'Zem-e.n~m'ZE'r!J*** :;:;

ElectIon to BJ.~ ..J..&~).?ht-.r!~~~~.I:'.~~.!.;' {Name of the House), /:1from .11?t!i.~K•..!§..<i!g.~!.~f.:..A~.~.!':t!&hstituenty. . '?'\"\\ \ DS'{i.1:> KHURSI-{ID MO~~MM> \1....; !'.1~}1~I.H (name of candidate.), son/d~r/~ of ~.~~~ ~~.§.'.~.~j:) IN ~ MPrl)

':,'; aged~_Q,_years, resident oft:1~.Ij~..~.!~.'?~.I.£:~:..~.l~.~~.~~.~/.~.L?!~~:..~.~.~.~.~ ,a candidate at the above election, do solemnly affirm and state on ~~~ as under:-

(i) 'have not been'allotted anyg()vt. acc;on'unodatlonat any tiMe during the period

6f last 10 yearsprior to the date of notlflc:at-lonof the c!Jrrentelection..... -

ORI have been allotted sovt. -accommod~tlori a't " • (mention the

ast 10 yearsaddress of the accommodation) during the period 0

prior to the date of notiflcation of the current

no arrears of any dues to be p' towards rent for the

(Iii)

e agencies providing electricity,

___ (the

date of the 3n1 month prior to the month in

concerned are attached

h

VERIFICATION