got pate ' ' i ‘ i 4 §s ; y iG i \Geet yee (See rule 4 A) __ TAPAS KANTI KUIRI : Before Sri/Smt~ Notary Public, Purulia Affidavit to be filed by the candidate alongwith nomination paper before the Returning officer for election to LOK SABHA - 2024 (Name of the House) from 35-PURULIA PC Constituency (Name of the Constituency). PART-A I BHAGWAT DASS SHASTRI ** Son/Daughter/wite of Late Shrikanta Shastri, ‘Aged 51 years, Resident of VILLAGE MURULAHAR, P.O. JIUDARU, PS KOTSHILA, District PURULIA (West Bengal), Pin- 723213 West Bengal (mentioned full postal address) a candidate at the above election, do hereby solemnly affirm and state on oath as under :- (1) Lam a candidate set up by NOT APPLICABLE, bee ati **p am contesting as an Independent candidate. (** strike out whichever is not applicable) (2) My name is enrolled in 241-JOYPUR WEST BENGAL (Name of the Con- stitueney and the state) at Serial No, 1155 in Part No. 110 (3) My contact telephone number(s) is/are 9419740649 and my HA e-mail id (if any) is bhagwat.shastri@gmail.com and my social media account(s) (if any) is/are (i) Facebook - Bhagwat Dass Shastri (Dragwak: Shag @ Facebook.com (ii) WhatsApp - 9419740649 (iii) NIL 1 G4 MAY 24 Bhaqualdass Shasten(4) Details of Permanent Account Number (PAN) and status of filing of Income tax return : [STNo. ]Names PAN "The nancial year [Total income shown Tn for which the last Income tax return has been filled income Tax Return (in [Rupees) for the last five {financial years completed (as on 31st March) 1 Self BQEPS2854K Not Applicable |i) Not Applicable (ii) Not Applicable (iii) Not Applicable (iv) Not Applicable (v) Not Applicable 2 Spouse GZVPD7627E Not Applicable (i) Not Applicable (ii) Not Applicable (iii) Not Applicable (iv) Not Applicable (v) Not Applicable 3 HUF (If Candidate is Karta/ Coparceener Not Applicable Not Applicable (i) Not Applicable (ii) Not Applicable (ii) Not Applicable (iv) Not Applicable ((v) Not Applicable i Dependent 1} No PAN Allotted ‘Not Applicable |i) Not Applicable (ii) Not Applicable (iii) Not Applicable \(iv) Not Applicable (v) Not Applicable | O4 way coy spate (4) Details of Permanent Account Number (PAN) and status of filing of Income tax return : for which the last |Income [STNo. Names PAN The financial year [Total income shown in Income tax return |Rupees) for the last five Tax Return (in (ii) Not has been filled | financial years completed (as on 31st March) (i) Not Applicable 5. Dependent? | No PAN Allotted ees (ii) Not Applicable Applicable (iv) Not Applicable (iii) Not. [(v) Not Applicable (i) Not Applicable 3 Not Applicable. § |-—————________+ Dependent 3! No PAN Allotted ne (ii) Not Applicable ‘Applicable (iv) Not. (v) Not Applicable Applicable Dependent 4 | No PAN Allotted Not Applicable (i) Not Applicable (ii) Not Applicable (iii) Not. (iv) Not. (v) Not Applicable Applicable Applicable allotted” “(5) Pending criminal cases indatory for PAN holder to mention PAN and in case of no PAN, it should be clearly Ai) 1 declare that there is no pending criminal case against me, (Tick ths alternative if there is no criminal case pending against the Candidate and write NOT APPLICABLE against alternative (ii) below) OR (i) The following criminal cases are pending against me : Not Applicable (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 of Police Station | NOT APPLICABLE] NOT APPLICABLE) |NOT APPLICABLH 3 Govt. of NOTARY PUBLIC oateroa Puta, OA MAY cig Chaguak i455 Share(b) Case NO. with Name of the Court NOT APPLICABLE|NOT APPLICABLE NOT APPLICABLE| © Section(s) of concerned Acts/ Codes involved (give no. of | the Section, e.g. Section NOT APPLICABLE|NOT APPLICABLE. NOT APPLICABLE| Application for revision has been filed against the proceedings (Menion YES or ‘NO) of IPC, ete.) + (@) | Brief description of offence | NOT APPLICABLE|NOT APPLICABLE | nor appLicaste| (©) | Whether charges have been No No No framed (mention YES or NO) (8 | If answer against (e) above| NOT APPLICABLE |NOT APPLICABLE. | NOT APPLICABLE] is YES, then give the date on which charges were framed (g)| Whether any Appeal/ No No No TAPAS KANTIKUIRI “Syosgrsm NOTARY PUBLIC cont of West Bengal, Pura O4 MAY coz Bhogualbass Shastrs(6) Cases of conviction : 1 dectare that I have not been convicted for any criminal offence. (Tick this alternative, if the candidate has not been convicted and write NOT APPLICABLE against alternative (ii) below) OR (ii) [have been convicted for the offences mentioned below : Not Applicable (Ifthe candidate has been convicted, then tick this alternative and score off alternative (i) above, and give details in the Table below) Table saan [NOT APPLICABLE] NOT APPLICABLE] NOT APPLICABLE (b) | Name of the Court INOT APPLICABLE] NOT APPLICABLE] NOT APPLICABLE JL ee IB a lt (©) | Sections of Acts/Codes or appLiCABLE| NOT APPLICABLE] NOT APPLICABLE involved (give no. of the Section, e.g. Section 1. OF IPC, etc.) NOT APPLICABLE] NOT APPLICABLE] NOT APPLICABLE | ascension po (©)| Dates of orders of | op appLiCABLE| NOT APPLICABLE] NOT APPLICABLE conviction (d) | Brief description of offence for which convicted NOT APPLICABLE] NOT APPLICABLE] NOT APPLICABLE (£) | Punishment imposed (g) | Whether any Appeal has been filed against NP No No conviction order (Mention YES or NO) TAPAS KANTI KUIRI TSS fi woman rust! s Govt. of Woe! Bengal, Purula 84 May aay @raguak oss shart(h) | If answer to (g) above is YES, NOT NOT NOT give details and present status. | APPLICABLE | APPLICABLE |APPLICABLE of appeal (6A) Ihave 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).Not Applicable [Candidates to whom this Item is not applicable should clearly write NOT APPLIABLE IN VIEW OF ENTRIES IN 5 (i) and 6 (i), above] Note: 1, Details should be entered clearly and legibly in BOLD letters. 2. Details to be given separately for each case under different columns against each item. 3. Details should be given in reverse chronological 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. idate is responsible for supplying all information in compliance of Hon'ble Supreme judgment in W.P. (C) No. $36 of 2011. (7) That I give herein below the details of the assets (movable and immovable etc) of myself, my spouse and all dependents : A. details of m issets : Note : I. Assets in joint name indicating the extent of joint ownership will also have to be given. 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 value 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 candidate whether by blood or marriage, who have no separate means of income and who are dependent on the candidate for their livelihood. TAPAS KANTI KUIRI ‘ Murry NOTARY PUBLIC Goon. of Weel Bengal, Puruia Shastn!serial No- se NY 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 Not Applicable (£) details of contracts, entered into by private companies in which candidate or spouse or dependents have share Not Applicable (10) My educational qualification is as under : Shastri (B.A.) from Sampumanand Sanskrit University, Kashi (U.P.) (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.) KUIRI A Preys oe oS 4 NAY culd 14 Bheguick OVS Shay?PART-B (11) ABSTRACT OF THE DETAILS GIVEN IN (1) TO (10) OF PART - A Name of the Candidate Ish /SmtKum. BHAGWAT DASS SHASTRI Full Postal Address VILLAGE MURULAHAR, P.O. JIUDARU, P. KOTSHILA, District PURULIA (West Bengal), Pin- 72321. WB. jumber and name of the nstitueney and State 24 }-loypur, West Bengal lame of the political party which t up the candidate (otherwise ite Independent) fotal number of pending Independent friminal cases Ne ffotal Number of cases in which wicted Ne of Year for which last Income | Total Income Shown Tax Return filed ay candidate POPS2854K | wn NIL, b) Spouse__|GZVPD7627E_| NIL NIL. (c) HUF, fot Applicable [NIL NIL (e) Dependents} NIL NIL. ils of Assets and Liabilities (including offshore assets) in in rupees scription _| Sel jpouse_[ HUF [Dependent - I [Dependent - 2] Dependent - 3 RS Rs. f: Moveable! sp.o00 | s.000-] Nm} NIL NIL NIL fotal value) Hmmovable] o> acrest | wi |NL| NL NIL NIL |Assets Dee uae hese, NIL | NIL NIL NIL NIL Rs. 1,90,000/ ff self-|¥* Jasco hacquired limmovable [property Lipeveloesment | NIG NIL | NIL NIL NIL NIL construction ost of limmovable lproperty after |purchase (if lapplicable) TAPAS KANTI KUIRI : huairch NOTARY PUBI kb Govt of Weal Bengal, Purulia 04 way cgIMI | Approximate Current market price - (a) Self- acquired 51200004 NIL NIL NIL | NIL | NIL assets (Total Value) (b) inherited assets 150.0001 NIL. NIL NIL | NIL | NIL (Total Value) b_[_ [Liabilities [ I | Government af dues (Total) NIL | NIL NIL NIL | NIL | NIL (ii) Loans from Bank, Rs. NIL NIL NIL | NIL | NIL Financial 2,00,000/- Institutions and others(Total) (0, _ [Liabilities that are under dispute i [Government ]-NIL NIC NINN NI [dues (Total) (ii)|Loans from Bank, NIL | NIL NL | NL | NIL NIL [Financial Institutions land others (Total) 1. [Highest edueational qualification : Shastri (B.A.) from Sampurnanand Sanskrit University, Kashi (U.P.) | (Give details of highest school/University education mentioning the full form of the certificat \diploma/degree course, name of the School/College/University and the year in which the course was completed.) KANTI KUIRI rer ort i vorrei Govt. of Wee! Bengal, Purulia 16 G4 mat cueVERIFICATION I, 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 part of it is false and nothing material has been concealed therefrom.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 ; (b) I, 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. Verified at Purulia this the 4th day of May 2024. croquatLys haste DEPONENT Note : 1. Affidavit should be filed latest by 3.00 P.M. 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. All columns should be filled up and no column to be left blank. If there is no information to furnish in respect of my item, either “Nild” or “Not applicable”, as the cae may be 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 Oath Commissioner or Magistrate before whom the Affidavit is sworn. Bhoguabsay Shas te - Beorf freddyak Gow! Under the Notaries Act. 1952 ibe poy aff rfswom g-ohs Binet Mens rants « ited District Session oige ‘cou Purulia TAPAS KANTI KUL NOTARY PUBLIC Govt. of West Bengal, Purvter G4 MAY 202 Chagiol bays Shayhrr