@

FORM 28
(See rule 4)
o
NOMINATION PAPER
Election to the Legislative Asse.uryMf- :....?:*?rr*

b
f

STRIKE OFF PART I OR PART II BELOW WHICHEVER IS NOTAPPLICABLE

PARTI

(To be used by candidate set up by recogrrised political party)

I nominate as a candidate for election to the Legislative Assembly from the..fiCH A.1'.fi- f\
CS a) ............... Assembly constituency.'

Candidate's name.Na.kkaxrlt .tfrpzrrkatra ..Sa.@",n .r..a.

Vt a .....
Father's/merle+#husbend's name.......\!3-Q)th.a$t*- ..................... His
postaladdress.D.rNp:...?.-.t5..,B.r.alrrnfrnl'.I-G*f..-Ac-f*.rh.5..a.g.r.SUi,
name is entered at Sl. No..9..4.3.. in Part No. ..!.p-.t...... of the electoral rof f for...Aghau.hl.C5!
Assembly constituency.

My name i...ka.nr.t-r.ruJl+r.il-e6.oragr" ....................... and

it is entered at st. No.6.l*5..m Part No..|3*rzof the electoral roll for the .A.cto^ 1a.C.56)
......Assembly
"onstit "n.y.?1

oate.2.L:Q.3.-2o17
a'[*#r%ra Signature ofPropbser
')
PART II
We hereby nominate as candidate for election to the Legislative Assembly from the
 at Sl.No.....f_...........in part No.........:i...............of the
electoral roll for..............
Assembly constituency.

we declare that we are erectors of this Assembly constituency

and our names are entered
in the electoral roll for this Assembry constituency as indipated
berow and we append our
signatures below in token of subscribing to this nomination:_

perticulars of the proposers

and their signatures
Sl.No. Elector Roll No. of proposer Full Name Signature Date
Part No. of Sl.No. in
Electoral Roll that part
I 2 3 4 5 6
I

4 w
5
e &tFv-
6
\5OK-
7

8 .r'
9

l0
I
N.B. - There should be ten electors ofthe constituency as proposers.

PART III
I' the candidate mentioned in part ypart II (Strike out which is not applicable) assent to
this nomination and hereby declare that -

(a) I am a citizen of India and have not acquired the citizenship of any foreign
State/Country;
(b) that I have completed..........5.r-..........years of age;

ISTRIKE OUT c(i) or c(ii) BELOW WHICHEVER IS NOTAPPLICABLET

(c) (i) l am set up at this election by,#:f .ry?f"r.W* ffiis
recognised National party/State party in this state and that the symbol reserved
for the above party be allotred to me.

OR

2
 (ii) I am set up at this election bv th2$loh.*'e0'fffqb;*r' which is a

registered qnrecognised political party/that I am contesting this election

as an

independent candidate. (Strike out which is not applicable) and that the symbols
I have chosen, in order of preference, are:-
(D.............................(ii).........................(iii).........

(d)mynameandmyfather,s/mother's/husband'snamehavebeencorrectlyspeltout
above in.E.NG.L.[.S'll (ou-" of the language); and
(e) That to the best ofmy knowledge and belief, I am qualified and not also disqualified
for being chosen to fill the seat in the Legislative Assembly of this State'
*I furrherdeclare that I am a member of 1he................*4.?.ti94.-bP-..1}*Caste/tribe which is
a scheduled **caste/tribe of the State oi.,..r-.f..9.(-.1....-............................in relation 1o...........
.(area) in that State'

I also declare that have not been, and shall not be nominated as a candidate at the pres-
I
ent general election/the bye-elections being held simultaneously, to the Legislative Assembly
f-of (State) from more than two Assembly Constituencies.
' t\'v.
oate.?L:.O-3:eol/ Signature of Candidate

*Score outthis paragraph, ifnot applicable.

**Score out the words not applicable.

,.recognised political party" means a political party recognised by the Election
N.B.-A
Commission under the Election Symbols (Reservation and Allotment) Order, 1968 in the State
concemed.

PART IIIA
(To be filled by the candidate)
(1) Whether the candidate:-

(i) has been convicted:-

(a) ofany offence(s) under sub-section (l); or

(b) for contravention of any law specified in sub-section (2) of *stNo/

. section 8 of the Representation of the People Act, 1951 (43 of
l95l): or , .

(il) has been convicted for any othff offence(s) for which he has been
sentenced to imprisonment for two years or more.
3
 If the answer is.,yes", the candidate shall fumish the following information;

(i) Case/first information report No./Nos....................f...MA.=....................

(ii) Police station(s).......2.N.H..... District(s)....--N{r--... strt"1, ).......d..:t.--. .

(iii) Section(s) of the concemed Act(s) and brief description

of the ofience(s) for which
he has been convicted................../_.!S..e.:......

(iv) Date(s) of conviction(s) ..............r_..\1.0 .:...........

(v) Court(s) which convicted the candidate........r.*C U:_............

(vi) Punishment(s) imposed [indicate period of imprisonment(s) and/or quantam of

fine(s)1.............. .............N.f
(vii) Date(s) of release from prison................;..$f.fiIa
(viii) was/were any appeal(s)/revision(s) filed against above conviction(s)....r-.......\tsa{o y'-
,, ,"or*l(s)/apprication(s) for revision nred....................... .......
":::-,.].:*:.:.,.::
(x) *:l ror revision nred
:::::::: ::;;Ilt'1p-'u'"*'"*'*s)
(xi) whether the said appeal(s)/application(s) for revision has,/have been disposed
ofor
is/are pending......... < t lO'-
(xii) Ifthe said appeal(s)/application(s) for revision hasrhave been disposed of-
(a) Date(s) of disposal............r,-.Nf
(b) Nature of orde(s) passed........./-ltltj--....
.
(2) whether the candidate is holding any office of profit under the Govemment of
India or
State Covernment?......... (.\+sfNo;,/
-If Yeq details of the office held......a-N..9.:...

(3) Whether the candidate has been declared insolvent by any Court?..$Q..
OHNo)/
-IfYes, has he been discharged from insotven"y...Nlk. ,q?licrh k--
(4) whether the candidate is under allegiance or adherence to any foreign
country?...*:.M
(Yes/Irlo)

-IfYes, givedetails................
1- IlOt oXlhe'a'bb' -
4
 Whether the candidate has been disquali$:d under section 8A of the said Act by an
(5) order

of the President? 15O QtaNoy'

-If Yes, the period for which disqualified.....rr2.o.l:.'X90h.CablA

(6) Whether the candidate was dismissed for comrption or for disloyalty while holding office
under the Govemment of India or the Govemment of any State? $@"'Of""Nel
-If Yes, the date of such dismissal....:a..M0t SPPlictbL-
(7) Whether the candidate has any subsisting contract(s) with the Govemment either in in-
dividual capacity or b). trust or partnership in which the candidate has a share for supply
of any goods to that Goverlment or for execution of works undertaken by that Govern-
rn.n,r..N.0...... (\<c,s/l'f ot /
-If Yes, with which Govemment and details of subsisting contract(s).lJ0f.*P#-cahfe-

(8) Whether the candidate is a managing agent, or manager or Secretary of any company or
Corporation (other than a cooperative society) in the capital of which the Central Govem-
ment or State Govemment has not less than twenty-five percent share?...N'0 .. Ucsho{
-lf Yes, with which Govemment and the details thereof .[9Ot..A.P.P

(9) Whether the candidate has been disqualified by the Commission under section l0A of the
saidAct...!).0.*... (Va6No) t /
-If yes, the date of disqualification...f0ol-.r\(flla'ca b h
prace: A&Iqal6 ' - N.v.S;9A-^^
Date:..L.L:03 '2-ol1 Signature of the Candidate
 PART IV
(To be filled by the Retuming Officer)
.
Serial No. of nomination paper ............1S.

This nominatlrn was delivered to me at my office at...).:.9.1...1hour; on.......................

(date) by the *caflrlidate/prcposer.....!.-1.,.V.,.I.af.61'nat"1,"rr*..".... (Name).

b f-.,[""t
neruJniugory,
oate.....M{.31r
1
* Score out the word not applicable.

PARTV
Decision of Returning Olficer Accepting or Rejecting the Nomination Paper

I have examined this nomination paper in accordance with section 36 ofthe Representation
of the People Act, 1951 and decide as follows:-

Date. Returning Officer

 g$;5reao do" $d5 P{d St g$6e,:$ $;6o
' (o.$ a"SbSdS: aod tq5o5: $oaoooa iFd $q5Jcldsg dd:"o)

$-13."- G-"<.=o..tgl3#*f;.le5 do5:a8 ao.go. a"55 $d (*do. a.5s

$odo) d$ E"Oc fo"ooJc-c3 o"arde5 do5:o8o"Xo. dr{5o6:s SSn /56gc$d o"as"6o6o ie
A6"550 gOR Jerod &obf6$5e*n e"66 K$g16 $65alxoo"5$;s.$66e$C s65>eao dQo";s:.

tdsP tuggo

diliou:c *o tur/ /g5e *$p..1a..}."lt...idna,.atrrg ...,r-i.6.*g.f,r..qgvor,u

t,
s65${r6s €,
95, 16oo; .......),,Sf-................ (6oe.:er) * osar ...}-f:l.zt,..g..I a" .......(.hg. 2b!1
-
5o56;6o o6,: o.5roo56 g6:.eoo $a"6.

b e.,-Jnr,J
sbds€-;!s(
$oao65 ep6s'B )
t o, .....[.,.9F.X xfr:... !- a.t.u€n
xd*, ....Pri..**.:*-3....d.U.W
I
 FORM OF' OAI-H OR AFFIRMATION
(To be made by a candidate for election to the Legislature oi'a State)

I..........'..... having been nominated as a candidate to fill

a seat in the Legislative Assembly (*or Legislative Council) do swear in the name of the God i
Solemnly affinn that I will bear true faith and allegiance to the constitution of India as by law
established and that I will uphold the sovereignty and integrity of India.

Signature and name in block

letters of the candidate

Sworn in the name of God/Solemnly affirmed by Shri/Shrimati

Signature of authorized person

Name and designation and Seal

(CERTIFICATE FOR RECEIPT OF OATH)

eeordtf dS'err*rvtfi ANDHRA PRADESH c H 24227 4
F$ /27e D =g-o*) >1)an) -
-g T.KRISHNA MOHAN
' Licensed Strirr: \':ndor
L.No. 05-2C ''397
OC t
R.l. No 05:20'Ju5i2.lii :': 2C20
Maremmaoudem, f er,ui:iltlda
Ftn I 634 320, cett : 9440479452

FORM 26

(See rule 4A) -'t

r.\ Alj c
bY G' .{ .,L\,
r\ ,6

"fi
t
t( ,TA. i 1

tl
-ir*9
AfFIDAVITToBEFILEDBYTHECANDIDATEALoNGt^,!THNoMINATIoNPAPERBEFoRETHE
orrr,rr,.r FR'M A.HANTA coNs*ruENcy No'
s6
ffi*i'ilffiH;";r;;;;;-;o
PART -A
SON Of VEERRAJU aged 57 Years,
resident of D'No'
flruCTK TUTI VENKATA SATYANARAYANA
Godavari District' AP' a candidate at the
above election do here bY
!-85, Achanta, West
lolemnly affirm and state on oath as under:-

t N^v
ATTESTED
t
$)
I',
I. NOTARY PUBLIC
West Godavari Disrrict A.p. INDIA
(1),1 am a candidate set up by INDIAN NATIONAL CONGRESS PARTY candidate.

(2) My name is enrolled in ACHANTA Constituency, West Godavari District, Andhra Pradesh, at
Serial No . 943, in Part No 105, Electoral Roll No. TYO0177451

(3) MV contact telephone'number(s) is/are 08814.236241, Mobile- 9+4L942999.

(4) Details of Permanent Account Number (PAN).and status of filing of lncome Tax return:

The Financial Total income

s!.No. Names PAN year for which shown in lncome-
the last tax return(in
lncome-tax Rupees) for the last
return has five Financial Years
been filed completed (as on
31't March)
1. (i)
NIL
Self AXDPNO3O9D NIL
Ntt
(ii)
NIL
(iii)
NIL
{iv)

(v)

NIL

2. Spouse (i)
No PAN allotted Ntt NIL

(ii)
Nlt

(iii)
Ntt

.1
/ N.rr
rf

NOTARY PUBLIC
Wost Godavari District A.P. INDIA
I

(iv)

Ntt

(v)

NIL

3. HUF (tf Candidate is Karta ,(a)

/Coparcener) NIL
No PAN allotted NIL

(ii)
NIL

(iii)
NIL

(iv)

Ntt

(v)

NIt

4. Dependent 1 No PAN allotted (i)

VEERA VENKATA NIL
SRIKANTH (Married since NIL
2010)
(ii)
Ntt

(iii)
NIL

ATTElTED
/ t* ,\,/.
R.V.sURY
NOTAFIY puBLl-c.-.^.^
. West Godavari District A'P' INDIA
 (iv)

NIL

(v)

NIL

5 Dependent 2 (i)
Tammina Sowmya( No PAN allotted NIL Nlt
Married since 2009)

(ii)
NIL

(iii)
NIL

(iv)

NIL

(v)

Ntt

Note: lt is mandatory for PAN holder to mention PAN and in case of no PAN, it should be clearly
stated "No PAN allotted"

(5) Pending criminat cases

(i) I dectare that there is no pending criminal case against me. (Tick this alternative if there is
no criminal case pending against' the Candidate and write NOT APPttCABtE against
alternative (ii) below)

l----FA atll "/ xt"v

$r
 a

(ii)The following criminal cases are pending against me;

(lf there are pending criminat the candidate, then tick this alternative and
cases against
score off alternative (i) above, and give details of all pending cases in the Table below)

Table

(a) FIR No. with name and NOT

address of Police Station NOT
APPTICABLE
NOT APPLICABTE
concerned APPLICABLE
(b) Case No. with Name of the NOT NOT
NOT APPTICABLE
Court APPLICABTE APPLICABLE
(c) Section(s) of concerned NOT NOT
Acts/Codes involved (Give NOTAPPLICABI.E
APPLICABLE APPL!CABLE
no.of section of lPG etc., ).
(d) Brief description of offence NOT NOT
NOT APPL!CABLE
APPLICABLE APPLICABLE
(e) Whether charges have been NOT
NOT
framed (mentioned YES or NOT APPLICABLE
APPLICABTE APPLICABTE
No)
(0 lf answer against (e) above NOT NOT
the date on
is YES, then give NOT APPLICABLE
APPLICABTE APPLICABLE
which charges were framed
(s) Whether
any Appeal/ApPlication for NOT NOT
revision has been filed APPLICABLE APPLICABLE
NOT APPLICABLE
against the proceedings
(Mention YES or NO)

(6) Cases of conviction

(i) I declare that ! have not bee.n convicted for any criminal offence. (Tick this alternative, if
the candidate has not been convicted and write NOT APPTICABLE against alternative
(ii) betow )

OR
;'l ft
(ii) I have been convicted for the offences mentioned below:
(lf the candidate has been convicted, then tick this alternative and score off alternative
(i) above, and give details in the Table below)

ATTESTFD

S.l
R.V. SURYANARAY
PALAKOL - 534 260
NOTARY PUBLIC.
West Godavari District A.P' INDIA
 Table

(a) Case No. NOT APPLICABLE NOTAPPLICABLE NOT APPLICABLE

(b) Name of the Court NOT APPTICABTE NOT APPLICABTE NOT APPTICABLE
(c) Section of Acts/
Codes involved (give
no. of the Section, NOTAPPTICABLE NOTAPPTICABLE NOTAPPLICABTE
e.g. Section.........of
lPC, etc.,)
(d) Brief description of
offence for which NOT APPTICABTE NOT APPTICABLE NOTAPPLICABTE
convicted
(e) Dated of orders of
NOT APPLICABLE NOT APPLICABLE NOT APPLICABLE
conviction
(f) Punishment
NOTAPPLICABTE NOT APPLICABTE NOT APPLICABLE
imposed
(e) Whether any Appeal
has been filed
against conviction NOT APPTICABTE NOT APPLICABLE NOT APPLICABLE
order (Mention Yes
or No)
(h) lf answer to (g) ,

above is YES, give

NOT APPTICABTE NOT APPLICABLE NOT APPTICABTE
details and present
status of appeal

(64) I have given fill 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).

[candidates to whom this ltem is not applicable should clearly write NoT AppLtcABtE tN
VIEW OF ENTRIES lN 5(i) and G(i), above I

Note:
1. Details should be entered ctearly and tegibly in BOLD tetters
2. Details to be given separatety for each case under different cotumns against each
item.
3. .Details shoutd be given in reverse chronotogical order ie., 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 atl information in comptiance of Hon,ble
Supreme Court judgment in W.p. (C) No. S36lZOLt.

ATTESTED

$+
R.V. SURYANARAYAN.A, B.^,,y
PALAKOL.534:
West Godavari District A.P. INDIA
(7) That I give herein below the details of the assets (movable and immovable etc.) of myself,

:...,:
A. Details of movabte assests:
Note:1. Assets in joint name indicating the extent of joint ownership willalso have to be
given.

Note 2: ln case of deposit/lnvestment, the details including Serial Number, Amount, date of
deposit the scheme, Narne of the Bank/lnstitution and Branch are to be given.

Note3: Value of Bonds/Share Debentures as per current market value in Stock exchange in
respect of listed companies and'as per: books in case of non-listed companies should
be given.

Note4: iDeponent' means parents, son(s) daughter(s) ofthe candidate or spouse and any other
person related to the candidate 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 assests.

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

Sl.No Description Self Spouse HUF Dependent- Dependent-

L 2

(i) Cash in hand Rs.50,0001- Rs.5,000/- Ntt

NIL NIL

(ii) Details of deposit 1) Rs.25001- in

in Bank accounts SBI Achanta Rs.3500/- in
(FDRs, Term Branch Andhra Bank
Deposits and all 2l Rs.3500/- in (Joint NIL NIL NIL
other types of Andhra Bank accountlAchanta
deposits including (Joint Branch
saving accounts), account)Ach

$r
/ Nl .\,,
R.V. SU RYA NA RAY*NAd( e.r.,
FALAKOL. 534 260
NOTARY PUBLIC
West Godavari District A.P. INDIA
 Deposits with anta Branch
Financial 3) Rs.1500/- in
lnstitutions, Non. Syndicate
banking Financial Bank
Companies and Achanta
Cooperative Branch
societies and the 4) Rs.2500/- in
amount ih each Cooperative
such deposit. Bank,
Kodamanchil
i Branch.
(iii) Details of
investment in
Bonds,
debentu res/sha res
NIL Nlr Nrt NIL NIL
and units in
companies/Mutual
funds and others
and the amount.
(iv) Details of
investment in NSS,
Postal saving,
lnsurance policies
and investment in
any Financial
instruments in
Post office or Ntt NIL NIL NIL NIL
lnsurance
Cornpany and the
amount.

(v) Personal loans Rs. 1,5O000/- in Rs.1,500fi1/- in

/advances given to Andhra Bank, Andhra Bank,
may person or Achanta Branch, Achanta Branch
entity including Rs.75,000/- in
firm, company, Co-operative
NIL
NIL NIL
Trust etc., and Bank,
other receivables Kodamanchili
from debtors and Branch.
the amount.

. .41
J Nr"V.
R.V. SURYANARAY\NA
PALAKoL - s3426-o
NOTABV PUBLTC
West Godavari District A.p. INDIA
(vi) Motor Honda Jazz Bajaj CT100
Vehicles/Aircrafts/ AP37 6 t t224 AP37 Aq0635,
Yatches/Ships ( 24lLOl2Ot6 2007
Details of Make, Rs.10,4O000/- Rs.60,000/-
Nrt NIL NIL
registration
number etc., year
of purchase and
amount)
(vii) Jewellery, bullion Chain -40 grms,
and valuable Ring-1,8-grms And its value is
thing(s)(give And its value is Rs. 1,20,000/-
details of weight Rs.24000/= Chain-16 grms,
and value) And its value is
Rs.aO000/-
Neclace- 40 grms
and its value is
Rs. 1,20,000/- NIL NIL NIL
Bangles-8, each
12 grms, and its
value is
Rs.36,000/-,
Rings-2, each 5
grms, and its
value is
Rs.30,000/-
(viii) Any other assets
such as value of NIL Nt! NIL NIL NIL
claims/interest
Rs.LL,24,OOO|- Rs.4,14500/-
NIL NIL NIL
(ix) Gross Total Value

B. Details of lmmovable 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 format.

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

.,,/ t.-l .V
NOTARY PUBLIC
West Godavari District A.P. INDIA
 Sl.No Description Self Spouse HUF Dependent- Dependent-2
1
(i) Asricultural 1) Rs.No Rs.No.489,
Land w8-2A, Thorredu,
Achanta, East.
Location(s) 2)Rs.No.268- Godivari NIT NtI Ntt
Survey 2, Achanta
number(s)

Area (total 1)Ac.1.70 Ac.4-00

measurements cents cents
NIL NIL NIL
rn acres) 2)Ac.0-09
cents
Whether
inherited
property
YES GIFT Ntt Nlt NIL
(Yes or No)
Date of
Purchase in case
of self Nil Nil N!L NIL NIL
-acqurreo
oropertv
Cost of Land (in
case of
purchase) at the Nil Nit NIL NIL NIL
time of
purchase
Any investment
on the land bay
way of
NIL NIL NIL NIL Ntt
development,
construction
etc.
Approximate 1)Rs.70 Rs.3
current market Lakhs Crores 20 NIL NIL NIL
value 2) Rs.4 Lakhs lakhs
(ii) Non;
Asricultural
NIt Ntt Ntt NIL Ntt
Land:
Locations(s)

V xl fr.
R.V, SU RYANARAYAM, g.L,LT,
NOTARY PUBLIC
West Godavari District A.P. INDIA
 Survey
number'(s)

Area (total
measurement in NIL Ntt Ntt N!L NIL
sq.ft)
Whether
inherited'
N!L NIL Ntt NIL NIL
proper:ty (Yes or
No)
Date of
purchase in case
NIL Ntt NIL Ntt NIL
,of self-acquired
propertv
Cost of Land (in
case of
Purchase) at the Nil- NIL Ntt NIL NIL
time of
purchase
Any investment ,

on the land by
way of NIL Nrt Ntt NIL NIL
development
construction
Approximate
current market NIL NIL N!L NIL NIL
value
Comrytercial
FqilCings
(including
apartments) Ntt N!L NlL NIL Nrt
-Locations(s)
.Survey
number(s)
Aiea
(total
NIL NIL Ntt NIL Ntt
measurement in
sq.ft)
Built-up Area
(total
measurement in NIL Ntt NIL NIL NIL
sq.ft)

ATTESTED

$l{ v, N.V.
R.V. S URYANARAYANA, B,I,\K,
PALAKOL. 534 W
NOTAFIY PUBLIC
West Godavari District A.P, INDIA
 Whether
inherited NtL N!L Nlt
NIL NIL
property (Yes or
No)

purchase ln case NIL

NIL NIL NIL N!L
of self-acquired
property
Cost of property
(in case of
purchase) at the NIL NIL NIL NIL Nrt
time of
purchase
Any investment
on the property
by way of NIL NIL NIL
NIL N!L
development,
construction
etc.,
Approximately
current rnarket NIL NIL Ntt NIL NIL
value.
Residential 1)D.No.9-82,
Buildines Assessment
(including no.972,
apartments); Achanta, Ntt
NIt NIL NIL
-Location(s) 2)D.No.9-83
-Survey Assessment
number(s) No.973,
Achanta
Area 1)900sq.feet
(total 2)500sq.feet
NIL NIL
NIL NIL
measurement in
sq.ft)
Built-up Area 1)900sq.feet
(total 2)500sq.feet
Ntt NIL N!L NIL
measurement in
sq.ft)
Whether
inherited ,

property (Yes or YES NIL NIL NIL NIL

No)

ATTEST.ED

$r
J t-J.v
R.V. s u RYAN A RAYAI{&!,!D,j
PALAKOL. 534 2IT_
NOTARY PU9LIO
Wesr 6odav"ri DistrlclA'P' INDIA
 Date of
purchase in case
Ntt NIL NIL
of self-acquired
property
Cost of property
(in case of Nil
purchase) at the NIL Ntr NIL NIL
time of
ourchase
Any investment
on the property
by way of NIL
NIL NIL NIL
NIL
development,
construction
etc.,

NIL NIL N!L NIL

NIL N!L NIL NIL

NIL

Total of current Rs.3

Rs. l Crore 12
Crores 20 N!L NIL NIL
mar:ket value of
Lakhs
(i) to (v) above lakhs

(8) I give here in below the details liabilities/dues to public financial intuitions and
government:-

( Note:-please give separate details of name of bank, institution, entity or individual and
amount before each item.)
 i.'

Description Self Spouse , HUF .Dependent- Dependent-2

Sl.No
t
(i) Loan or dues to Rs. Rs.

Bank/financial 1,50,000/- in 1,50,000/-

institutiqn(sl Andhra Bank in Andhra NIL NIL Nlt
Name of the bank , Achanta Bank,
or financial Branch, Achanta
lnstitution, Rs.75,000/- Branch
amount in Co-
outstandi ng, operative
Nature of loan. Bank,
Kodamanchili
Branch.

Loan or dues to
any other
NIL NIL NIL NIL N!L
individuals/entitY
other than
mentioned above
Name(s), Amount
outstanding,
nature of loan
NIL NIL NIL NIL
Any other liabilitY NIL
Rs.1,50,000/- NIL NIL NIL
Grand total of Rs.2,25,000/-
liabilities
(ii) Government due: (A) ttis theloeponent in occupation of ffilNO\/
(Pl.tick the
Dues to accommodation Provided bV the
Departments Government at anytime during the last ten appropriate
year before the date of notification of the alternative)
dealing with
Government -
accommodation.
(B) lf answer to (A) above following
is YES, the
declaration may be furnished namely:-
(i) The address of'the Government NO
Accommodation:

(ii) There is no dues payable in respect of

above, Govern ment accommodation,
towards
(a) Rent;
(b} Electr:icitY charges
(c) Water: charges and
(d) TelePhone charges as on

$.r
J t{"\r.
'
iiOrinY PUBLIo -..
west dioiuari District A'P' INDIA
{

, Ithe date should be the alto date of

the third month prior to the month in
which the election is notified or any
date thereafterl.

Note:- "No Dues certificate from the

agencies concerned in respect of rent,
electricity charges \ water charges and
telephone charges for the above
Government accommodation should be
submitted.
(iii) Dues to .

department
dealing with
NIL NIL NIL NIL NIL
Government NIL
transport
(including aircrafts
and helicopters)
(iv) Income tax dues
Self Spouse HUF Dependent-1 Dependent-2
(v) GST Dues NO NO NO NO NO
(vi) Municipal NO NO NO NO
No
/property tax
dues
(vii) Any other dues NO NO NO NO NO
(viii) Gran total of all NO NO NO NO. NO
Government dues
(ix) Whether dryr.. NO NO NO NO NO
other 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 :- Cultivation

(b) Spouse:- House wife

(9A) Details of sources of income:

(a)Self:- Cuttivation
/'$ v
R.V, SURYANARAY

NOTARY PUBLIC
. West Godavari District A.P. INDIA
 (c) Sources of income, if any of deponents NIL
(98) Contacts with appropriate Government and any'public company or companies

(a) Details of contracts entered by the candidate:- NIL

(b) Details of contracts entered by the spouse:- Nlt

(c) Details of contracts entered by the dependents:- NIL

(d) Details of contracts entered by Hindu Undivided Family or trust in which the
candidate

or spouse or dependents have interest NIL

or spouse or
(e) Details of contracts entered into by partnership Firms in which candidates

dePendents are Partners NIL

candidate or spouse or
, (f) oetails of contracts entered into by private companies in which

dePendents have share NIL

(10) My educational qualification is as under :-

9m class
/ N.\.

Rv. SURYANARAIAhI*d
PALAKOL . 534 260
NOTARY PUBLIC
Wesl Godavari District A'P' INDIA
l_
A.

PART-B

(11) ABSTRACT OF THE DETlAls GTVEN tN (1) TO (10) OF,PART-A:

L. Name of candidate N EKKANTI VEN KATA SATYANARAYANA

2. Full postal address
T:-Jflll'a"^ox
Achant4 5 3+ t 2-3
nus httat ffi, i
\niot^t
West Godavari District, AP
3. Number and name of the ACHANTA, No.56
consistency and state
4. Name of the political party TNDIAN NATIONAL CONGRESS PARTY
which set up the candidate
(otherwise write independent)
5. Total number of pending NIL
criminal cases -rrta
6. Total number of cases in which
NIL q^{nys)
convicted !
7. PAN of Year of which lasQ Total income
income tax return field shown
(a) candidate AXDPN0309D N!L Nlt
(b) Spouse No PAN allotted NIL NIL

(c) HUF No PAN allotted NIL NIL

(c)Dependen No PAN allotted
NIL NIL
ts
8. Details of Assets and Liabilities in Rupees
Sl.No Description Self Spouse HU Dependen Dependent-ll
F t-l
A. Movable Assets Honda Jazz Bajaj
(Totalvalue) AP37 CW cTl00
L224 AP37 Aq
24lLO|2OL6 0635, Ntt NIL Nlt
Rs.10,40,000 2007
t- Rs.60,000/

B. !mmovable 1)Rs.No Rs.No.489,

Assets' L78-24, Thorredu,
Achanta, East
2)Rs.No.268- Godavari NIL NIL Nlt
2, Achanta

ATTESTED
,,/ N, v-
Rv.sglllHltls**ls"
NOTABY PUBLIC
West Godavari District A'P' INDIA
.)

t. Purchase Price
of Self-Acquired
immovable NIL Ntt NIL NIL Nttt
property

lt. De-velopment/
construction
cost of
lmmovable NIL N!L N!L NIL Ntt
property after
purchase (if
applicable)
ilt Approximate
Current rnarket
Prlce-
(alself-Acquired
assets (Total NIL N[. NIL NIL N!L
Value)
(b) lnherited
assets (Total
Value)
9. Liabilities
(i) Government
dues (Total) N!L Ntt Ntt NIL NIL

(ii) Loans from Rs. Rs.

Bank, Financial 1,50,000/- 1r50r00
lnstitutions and in Andhra ol-in
others (Total) Bank, Andhra
Achanta Bank,
Branch, Achant
NIL NIL NIL
Rs.75,000/- a
in Co. Branch
operative
Bank,
Kodamanch
ili Branch.
10 Liabilities that are under dispute
(i) Government N!L NIL NIL NIL NIL
dues (Total)
(ril Laons from
NIL NIL NtL NrL Nlt
Bank, Financial
lnstitutions and
I
v1' N, 11 ,

NOTARY PUBLIC
Wesl Godavari District A.P. INDIA
 (
,

LL, Highest educational qualification:

gth cLAss

VERIFICATION
l, 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 and no par:t of it is false and

nothing material has been concealed there from' I further declare that:-

qgainst me other that than those

{a) there is no case of conviction or pending case
mentioned in items 5 and 6 of Part A and B above:

(b) l, 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 item 8,9 and 10 of
part B above.

Verified at Palakolthis day of 20th March, 2019'

-/ru.\. DEPONENT

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

filing nominations'

Magistrate of the First

Note:- 2. Affidavit should be sworn before an oath Conryfssioner or
Class or before a Notary Public.

lf there is no
Note: 3 All columns should be filled up and no column to be left blank.
as the case may
information to furnish.in respect of any item, either :Nil: or 'lNot Applicable",

Note :4 . The Affidavit should be either typed:or writteh legibly ind

neatly'

t-tre Affidavit should '

Note :5. Each page of the Affidrvit should be signed !v'the. deponent'a!
bear on each page the stdmp of the Notary or Oath Commissioner
or Magistrate before whom
the Affidavit is sworn.

ATTEST

$) i Revcnuc Rcgd. DePanment

R.V. SURYANARAY NOTARY PUBLIC .rocrr ments ontruns.-\3-- rrrr
PALAKOL: 534 260 QORT 1'lo. 893
NOTARY PUBLIC Vdkl Wto 21+2OZg i no b u,u....J.*,r.r
West Godavari District A.P. INDIA '---.'_ -'1 -.:..