- - ---------------------------------------------------

FORM2A
(See rule 4)
NOMINATION PAPER
Election to the House of the People

be attached.

STRIKE OFF PART I OR PART II BELOW WHICHEVER IS NOT APPLICABLE

PART I
(To be used by candidate set up by recognised political party)

I nominate as a candidate for election to the House of the People from

the Parliamentary constituency.
Candidate' name............................................... Father's/mother'slhusband's name ..
........................ His postal address ,
His name is entered at S.No .in Part No....................... of the electoral roll
for.. Y(Assemblyconstituency comprised within) Parliamentary
Constituency.
My name is........................................................ and it is entered at S.No in Part
No of the electoral roll for :(Assembly constituency
comprised within) Parliamentary constituency.

Date . Signature of Proposer

PART II
(To be used by candidate NOT set up by recognised political party)

We hereby nominate as candidate for election to the House of the People from
~
Z
I the..;20.:::...B£lZJ+'A:N.P.L'R. Parliamentary Constituency ~
o Candidate's name. B.'..e.~~.\:\.~.~...~AAS.~~...Sue.\). J).~~ ..... Father'S/Hl6thef'sllNlsband's
i=
o
W
.....J
namev. ..5.:.~.P.t:T.~y.P.r..t:l.!T.KA~.~.~.~~~p~ltal address.P.ggfr.t'--"·A~~1!!r.~::.~.r.~.J-;~'£
W
w 8.£R\-\-~l:<:l.B)R.:-.:t~CO"'2 .
::?:
o
J:
M
C')
1
......
 v
His name is entered at S.No 45.'.~: .in Part No 5.,i.;..: ofthe electoral roll for
....l.3.3::·B.~w..M.P9.¥.\ y(Assembly constituency comprised within)
'".20..:7 8.g.R.tH~.tl.?\.?~ Parliamentary constituency.

We declare that we are electors of the above Parliamentary Constituency and our names are
entered] in the electoral roll for that Parliamentary Constituency as indicated below and we
append ;pursignatures below in token of subscribing to this nomination:-

Particulars of the proposers and their signatures

Sl.nool Name of Elector Roll No. of Full Name Signature Date
component Proposer
Assembly Part No. of S.No. in
Constituency Electoral that part
Roll
-~---.--.--- t----- -
1 2 3
--_._-----..1..-..- --_ 5 6 7
l.~AM /
\_/
\~ - ~
2. BA 7:<1
3. tJAI'1
4. BAM
5.~-
6. () I1-M
7·B~
8. ~~
9. BAM
10. t3 ft' P'\

N.B.- There should be ten electors of the constituency as proposers.

PART III
I, the candidate mentioned inyro1i/Part II (Strike out which is not applicable) assent to
this nomination and hereby declarc-;
(a) that I am a citizen of India and have not acquired the citizenship of any foreign
State/country.
(b) that I have completed 54 years of age;
[STRIKE OUT cCi)or cCii)BELOW WHICHEVER IS NOT APPLICABLE]
(c) (i) that I am set up at this election by the....:,N.(rT....A.P..f:?4:-i:.LA.3!....£.......
party, which is a recognised National Party/State Party in this State and that the
symbol reserved for the above party be allotted to me.
OR
2
 (c) (ii) that I am set up at this election by the b.t:1.J?J~.P.g·J:iJ).~~.T. .
party, which is a registered-unrecognised 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:-
(i) (ii) (iii) ..
(d) that my name and my father's/mother'slhusband's name have been correctly spelt out
above in...Et.:\.~.b.+..$..\;L .. (name of the language);
(e) that to the best of my knowledge and belief, I am qualified and not also disqualified
for being chosen to fill the seat in the House of the People.

*1 further declare that I am a member of the..N.Qr..AJ?2.sI:5:.fr.r?..4:-.r;. **Caste/tribe

which is a scheduled **caste/tribe of the State of..Na.r.....lTf?.P.l;;.~~Tb.-:e.bE in relation
to (area) in that State.
I also declare that I have not been, and shall not be nominated as a candidate at the present
general election/the bye-elections being held simultaneously, to the House of the People from
more than two Parliamentary Constituencies.

(})~J\~c) ~.
Date .. Signature of Candidate

YScoreout the words "assembly constituency comprised within" in the case of Jammu and

I Kashmir, Andaman and Nicobar Islands, Chandigarh, Dadra and Nagar Haveli, Daman and Diu
and Lakshadweep.
*Score out this paragraph, if not applicable.
**Score out the words not applicable.
N.B.-A "recognised political party" means a political party recognised by the Election
Commission under the Election Symbols (Reservation and Allotment) Order, 1968 in the State
1
concerned.

PART IlIA
(To be filled by the candidate)
(1) Whether the candidate-
(i) has been convicted-
(a) of any offence(s) under sub-section (1); or
(b) for contravention of any law specified in sub-section (2),
V
of section 8 of the Representation of the People Act, 1951 (43 of 1951); or YeslNo
(ii) has been convicted for any other offence(s) for which he has been
sentenced to imprisonment for two years or more. NO
3
If the answer is "Yes", the candidate shall furnish the following information:
(i) Case/first information report No./Nos 1. :' ~ .. : .
(ii) Police station(s) N,..(7:.. : .
District(s) N., Pl. Staters) f:':\\:. A::.. : . (8
(iii) Section(s) of the concerned Act(s) and brief description of the offence(s) for which he
has been convi cted ~ .'.A-- , ..
...... - .
(iv)Date(s) of conviction(s) :;-.t. A ..
(v) Courtts) which convicted the candidate N.A- ..
(vi)Punishmcnt(s) imposed [indicate period of imprisonment(s) and/or quantum of e
fine(s)] N.,..Pr. : .
(vii) Daters) of release from prison .
(vi~Was/were any appeal(s)/revision(s) filed against above conviction(s) .... H... ft....
Yes/No
(ix) Date and particulars of appeal(s)/application(s) for revision filed N.:..1\.." .
1
(x) Name of the court(s) before which the appeal(s)/application(s) for revision filed .
N..'./:r.
............................ .
(xi) Whether the said appeal(s)/application(s) for revision has/have been disposed of or
is/are pending .... N'..f1
(xii) If the said appeal(s)/application(s) for revision haslhave been disposed of-
(a) Daters) of disposal. N.: ..
fT..: .
(b) Nature of ordcr(s) passed J:{_,.. A- .
(2) Whether the candidate is I!~ng any office of profit under the Government of India or State
Government? ........ (.¥etlN 0 ) NO
-If Yes, details of the office hcld......... ~
(3) Whether the candidate has been declared insolvent by any Court? (¥e&No) NO 1
-If Yes, has he been discharged from insolvency " .
(4) Whether the candi~ IS under allegiance or adherence to any foreign
country? (¥eslNo) NO
-If Yes, give details .
(5) Whether the candidate has been disqualified under section 8A of the said Act by an order of
............
the President? (¥ett/No) NO
-If Yes, the period for which disqualified .
(6) Whether the candidate was dismissed for corruption or for disloyalty while holding office
'''''''---
under the Government of India or the Government of any State? (~o) NO
-If Yes, the date of such dismissal. .
(7) Whether the candidate has any subsisting contract(s) with the Government eithor
individual capacity or by trust or partnership in which the candidate has a share flU "
4
--------- -" " _

of any goods to that GO~9JlIl1ent or for execution of works undertaken by that

Government? (¥es1NO) NO
_If Yes, with which Government and details of subsisting contract(s) .
........................................................................................................
(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
,_____
Government or State Government has not less than twenty-five percent share? .
(¥es/no) NO
-If Yes, with which Government and the details thereof .

(9) Whether the candidate has b~ disqualified by the Commission under section lOA of the
said Act (¥es/No) NO
-If yes, the date of disqualification .

Place: .
Date: .

PART IV
. (To be fi~ed b~ the Re~min~ Officer)
Serial No. of nomination paper .....~\)..t·"lfk.~J::\··\
1t.\ ' fl"" Sb O-~
:~is\, nomination was delivered to me at my office at. (hour)
on 1!?f?\'~..
(date) by the *candidate/prop6s"er.(name ofproposer .
.................... )

Date .

PARTV
Decision of Returning Officer Accepting or Rejecting the Nomination Paper
I have examined this nomination paper in accordance with section 36 of the
Representation of the People Act, 1951(43 of 1951) and decide as follows:-
.......................................................................................................................
......................................................................................................................
.....................................................................................................................

Date...... Returning Officer

................................................ (Perforation) .
5
 PART VI
Receipt for Nomination Paper and Notice of Scrutiny
(To be handed over to the person presenting the Nomination Paper)
Serial No. of nomination paper .
The nomination paper of .......................................• a candidate for election from
the Parliamentary constituency was delivered to me at my office
at.. (hour) on (date) by the *candidate/proposer. All nomination papers
will be taken up for scrutiny at.. (hour) on (date) at. .
........... ..(Place).

Date .
Returning Officer

*Score out the word not applicable.

6
OGP-MP-CTCP (HOME ELEC.) 133-5,000 Bks.-18-2.2019
 (3~~11 3"ilf6~!1 ODISHA
I
FORM-26
([Jr. 1G9Il. ~nl8raliy (See rule-4A)
NOTARY
f Berharnpur ~arijam)
NO·····/r·'!.'~~~.
!t.~
I
Time
Place: ~lr;·~
BEFORE THE NOTARY PUBLIC, BERHAMPUR, (GM)
AFFIDAVIT
Affidavit by the candidate along with nomination paper before the
, Returning Officer for election to House of the People ( (Name of the House) from
, .Berhampur Parliament Contituency-20 ((Name of the Constituency)
I PART-A
I I, Sri B. BISHNU PRASAD SUBUDHI, Son of Late B. Satyanarayan
. Subudhi, aged a~~ years Resident of At-Prem Nagar 5"' Lane,
; , PO:Berhan:pur, PS:. i;DtM,jam, Pin-7600' ~6disha, a candidate at the
above election, do hereby so?en;i;;ffirm and state on oath as under:
~~R,~RTl) I am contesting as an Independent candidate.

NOTA~
~y rtA
,
-:(~J
r1
tflJEL l.AJ", name is enrolled in 133 Berhampur Assembly Constituency, Odisha
(Name of the constituency and the State), at Serial No. 452 in Part No. 52.

I
 34~~ 21{3/'1 .
51. No Ot. RS.• I.d:::::. .
Name: !3.: I2(/.1I:t.'h.~....!.r.~acJ StvblA/~'
~,~

Address .......•..•.. I2.J:.a ..~.~ TrF~:-1S1'V O~f;"-:0r

Snt.'ClJ! ri.", __ ',,- ""1',
., ~ ,I. L" " ('t.: f \,

Santilata~
Stan ,; ','endor
Civil COUll, Gr8~'rnc~lJr
 2

(3) My contact telephone Number(s) is Cell: 9437616720 /8328955171.And

my e-mail id is : [email protected] and my social media account(s) are
i) [email protected]
ii) 9437616720@Whatsup

(4) Details of Permanent Account Number (PAN) and Status of filing of

~~!_ti;~
-
--
Income Tax return
Names PAN The Financial year
for which the last
Total Income shown in
Income Tax return (in
J....~ ' """~ ,', income-tax return Rupees) for thelast five
01 '
'Z. - '<: ; - , ·-l,
r- -
~
\
:. .''' «, has been filed Financial Years(as on the
\
~
<'> .:
'i/," ,,',; t
-""I
C f'1'/.
%,
"'-

Self AFNPB8866R
31st March)
" ,,<, 2005-06 2005-06-1,50,000
~Ot'~~f " t-:/ '
•• ,J /".
B_BISHNU
Nil
'''''.:.:...-:~. ,f'

PRASAD NIL
SUBUDHI NIL
NIL
Unmarried

2_ Spouse Not Applicable Not Applicable NIL

NIL
NIL
NIL
NIL
3_ HUF(if the Not Applicable Not Applicable NIL
Candidate lS NIL
Karta or NIL
< Coparcener)
"

NIL
NIL
4_ Dependent-l Not Applicable Not Applicable NIL
NIL
NIL
NIL
5_
NIL
Dependent-2 Not Applicable Not Applicable NIL
NIL
NIL
NIL
15- Dependent-3
NIL
F i'.l Not Applicable Not Applicable NIL
~<
( /

NOT,~ ~'~
,~
C-','
,\,~
"
~/

/ NIL
NIL
NIL
NIL
 3

(5) Pending criminal cases

(i) The following criminal cases are pending against me:
Table
<c
, (a) FIR No. with Not Applicable Not Applicable Not Applicable
"'I( .. tI '(i"":-., name and
J.-'q'~~,/' ~ .~:
o rs ~'~.'
s'"~ ~\
'~'''''\\
address of Police
Station
concerned
~~*:;1'~:,d' ~1-I~..J.'·--l-c-a-s-e-N-.
o-.-w-i:-:th:-+--N-o-t
-A-p-p-li-ca-b--I-e--+-=-N=-o-t-=A-p-p-=-li=-c-ab:-:l=-e--!t-:N::-:
~~r!(}v..,..
,......... ,.~~~:
~"
-
(b) Name of the
'-':.:.:::=-,.,... Court

(c) Section(s) of Not Applicable Not Applicable Not Applicable

concerned
Acts/Codes
involved(give no.
of the Sections,
e.g.
Section ....... of
IPC, etc.)

(d) Brief description Not Applicable Not Applicable Not Applicable

of offence

Whether charges Not Applicable Not Applicable Not Applicable

have been
(e) framed(mention
YES or NO)

(f) If answer Not Applicable Not Applicable Not Applicable

against(e) above
is YES, then give
the date on which
charges were
framed

p ,I). ,.~ T(g) Whether any Not Applicable Not Applicable Not Applicable
FCO\\~~tt;'jj~~~7'.
\, . ?/(yAppeal/AppI~c~ti
Y ;-,
\~
~'r; T (\ o>
11,' / on for revision
Q ''-..J has been filed
against the
proceedings(Men
tion YES or NO)
 4

(6) Cases of conviction

(i) I declare that I have not been convicted for any criminal offence.
OR
I have been convicted for the offences mentioned below: NOT
",,'
'~~.r c':,\,4 APPLICABLE
:/ ~ ' .~,
;
_:tl Table
V(~l
.

/,_J~ ...'r-" -,
, T' _) [;-:- ;-_-,.,_-. Case No. NOT NOT NOT
L 1 I"
(<_ ....-;
0-/ 4 APPLICABLE APPLICABLE APPLICABLE
~:~
--,--- lJf
Name of the Court NOT NOT NOT
(JVT. ?~ APPLICABLE APPLICABLE APPLICABLE
(c) Section(s)of NOT NOT NOT
concerned Acts/ APPLICABLE APPLICABLE APPLICABLE
Codes involved(give
no. of the Sections,
<r ' e.g. Section....... of
IPC, etc.)

(d) Brief description of NOT NOT NOT

offence for which APPLICABLE APPLICABLE APPLICABLE
convicted

(e) Dates of orders of NOT NOT NOT

conviction APPLICABLE APPLICABLE APPLICABLE
(t) Punishment imposed NOT NOT NOT
APPLICABLE APPLICABLE APPLICABLE
(g) Whether any Appeal NOT NOT NOT
has been filed APPLICABLE APPLICABLE APPLICABLE
against conviction
~ , order(Mentioned
YES or No)

(h) If answer to(g) above NOT NOT NOT

is YES, give details APPLICABLE APPLICABLE APPLICABLE
and present status of
.,-, {} t3--r appeal
,'" II
Fe) '" ' !,
C"
'
., •

;'''-
/[
·:~,-' ,." 114''{[Ai have~ven 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). '
 5

(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 Movable assets:

....-: ~
Description Self
*.!!~~~ fc.h,-"""';' './
Spouse HUF Depend
ent-l
Depende
nt-2
Dependen
t-3
Cash in hand 2,40,000 Not Applicable Not Not Not Not
,r;;
t\~~· ~~>~~ \\
Applic Applicab Applicabl Applicable
. -: c., :.. J,.. I able Ie e
,<')
c,_)
.. ",' ';
ItJ r:.:
011 in Bank Accounts Branch,
fIJi._ ,~ 1 Details of deposit UGB, Badabazar Not Applicable Not
Appli
Not
Applic
Not
Applica
Not
Applicabl
..~:. ~
0/1 (FDRs, Term Berhampur SB
Deposits and all
; ,. Alc
cable able ble e
°VT. ~:, ./
. ---...:-..~~"" other types of
deposits including
No.13536303239
Rs.61317.00 as on
saving accounts), 21.03.2019
Deposits with
Financial
Institutions, Non-
Banking Financial
Companies and
Cooperative
Societies and the
amount in each
such deposit.
(iii) Details of NIL Not Applicable Not Not Not Not
investment In Appli Applic Applica Applicabl
Bonds, cable able ble e
,
<
debentures /
shares and
units In
companies /
Mutual funds
and other and
the amount.
(iv) Details of NIL Not Applicable Not Not Not Not
investment In Appli Applic Applica Applicabl
NSS, Postal cable able ble e
Savings,
Insurance
Policies and
investment In
any Financial
- .J!, ;::).:\ ·;;"r
lnstruments In

rr~
OJ -, t,~

..Post Office or
. ~/,.. Insurance
Company and
the amount.
 6

(v) Personal loans NIL Not Applicable Not Not Not Not
/ advance Appli Applic Applica Applicabl
given to any cable able ble e

(vi) Motor vehicles Suzuki Zues mle Not Applicable Not Not Not Not
/ Aircraft / bearing Regd. Appli Applic Applica Applicabl
Yachts/ No.OR 07V 2711 cable able ble e
Ships(Details Model-2010
of Make, Value-
Rs.56,OOOI-
registration
Number etc.
and year of
purchase and
amount)
Jewellery, About 290 gm. Not Applicable Not Not Not Not
bullion and Gold Appli Applic Applica Applicabl
valuable About cable able ble e
(vii) things(s) (give Rs.8,00,000.00
details of
weight and
value)
(viii) Any other NIL Not Applicable Not Not Not Not
assets such as Appli Applic Applica Applicabl
values of cable able ble e
claims /
interest
(ix) Gross total Rs.I0,96,000.00 Not Applicable Not Not Not Not
Value Appli Applic Applica Applicabl
cable able ble e

i'
:vz/>/{f
~
 7

B. Details of Immovable Assets:

S.No. Description Self Spouse HUF Dependent-l Dependent-2 Dependent-3

(i) Agricultural NIL NIL NIL NIL NIL NIL

Land

Location(s)
Survey
Number(s)

.,< Area (total NIL NIL .NIL NIL NIL NIL

/ -: ~.. -.:: ...... _. measurement

/,'
~"... ..........
'" ~i. . \

.'
'.
in acres)
r
,i Whether NIL NIL NIL NIL NIL NIL
. .inherited

-~-~
'property (Yes
,
'A.,"' ' II. ;"/
-< ,-

-
,~::
I '
'()' J-or No)

-_ VO./
',..... '-./:-

" ':' ... ,~

"'~Jr. c ,tr, , -'

Date of NIL NIL NIL NIL NIL NIL
-..... .....
purchase in
case of self-
acquired
property.

< 'Cost of Land NIL NIL 'NIL NIL NIL NIL

(in case of
purchase at the
time of
purchase)

Any NIL NIL NIL NIL NIL NIL

investment on
the land by
way of
development
construction
etc.

Approximate NIL NIL NIL NIL NIL

~
NIL
current market
FO,~M F ZI value

LO TP,. r<."
,f\
~'" '. ,_.\~>~/'l
~I~!
.
d

5
 8

S.No. Description Self Spouse HUF Dependent-l Dependent-2 Dependent-3

,
(ii) ._
Non- NIL NIL NIL NIL NIL NIL
Agricultural
Land

Location(s)
Survey
Number(s)
O~\) ~
-4\;. -; ._" Area (total NIL NIL NIL NIL NIL NIL
. ",.~ '1:'~,
'f "" ,~ . 0., .;.., ~~easurement
i i ..::
"-.;" ':} ~~
'''/" "7;_,(- n sq. ft.)
i i >.
.'-: ) u,
I
\ \:ot \~ (" \'>, ("!i. 0
, ...~.

~~"'\"'('
/.

" 't ,...

-~""
l~,_:, \~
V<./
",'~
: ;"
....
I!Whether
".~ inherited
NIL NIL NIL NIL NIL NIL
..~.... . , rf ~ G ~. -:

property (Yes
-.~.:' -~=:;:;.V
-.:
.orNo)
'.

Date of NIL NIL NIL NIL NIL NIL

purchase in
case of self-
acquired
property.

Cost of Land NIL NIL NIL NIL NIL NIL

(in case of
purchase at the
time of
purchase)

Any NIL NIL NIL NIL NIL NIL

.investment on
~
the land by
way of
development
construction
etc.

Approximate NIL NIL NIL NIL NIL NIL

current market
value
..:l.
I p,A..,'" I

NOTA~
 9

S.No. Description Self Spouse HUF Dependent- Dependent- Dependent-3

1 2

(iii) Commercial Building NIL NIL NIL NIL NIL NIL

","t\ y .~ (Including

;-,I}
-<. - ; apartments)Location(s)
o \)'\'\('I~~ ~\
J ~., '" _ ~ ~-'\ Survey Number(s)
, ~
I '-<:,'",'
-,'

, :,~ ','
... .: ", ,'J .' j ..f._,<
",
..' Area (total NIL NIL NIL NIL NIL NIL
~ C' \
,.
r:"
."l.
r:
-,
..... ~......
........ ~
., ' ",
'.'C'
.',
_., - ./
~".... "
,
..... ,'\:
,
..•.
'

"..'
" measurement in sq.ft.)

-< ':,:;~:' .: "

Built-up area (total NIL NIL NIL NIL NIL NIL
measurement in sq.ft.)

Whether inherited NIL NIL NIL NIL NIL NIL

property (Yes or No)

Date of purchase in NIL NIL NIL NIL NIL NIL

case of self-acquired
property

Cost of property (in NIL NIL NIL NIL NIL NIL

.~ case of purchase) at
the time of purchase

Any investment on the NIL NIL NIL NIL NIL NIL

land by way of
development,
construction etc.

Approximate current NIL NIL NIL NIL NIL NIL

market value

FORM p ,6..f< ,-'

,JY PUBIJC
NOT"
 10

S.No. Description Self Spouse HUF Dependent- Dependent-2 Dependent-

1 3

(iv) Residential NIL NIL NIL NIL NIL NIL

Building

(Including
-r<
apartments)
Location(s)
~~!l\
~

0~ ~Survey Number(s)
"~

• ,\)f. ". of
~
~
,."
o 1 1? c<'
L"\ ..~\
,,,, '."'.
NIL NIL
-< 1\ measurement NIL
'~-); ~ I\rea (total NIL NIL NIL
\\ ."""
o ~~~~, /~

I,."
' . . "i:
.' . in
\"'-.

. .,.~,._:_ /'
:'"
1Isq. ft.)
.~
)~
··..·A ,ii:10--:
.."' ...;:.........._..,
....... Built-up area (total NIL NIL NIL NIL NIL NIL
measurement in
sq. ft.)

Whether inherited NIL NIL NIL NIL NIL NIL

property (Yes or
<
"' "No)

Date of purchase in NIL NIL NIL NIL NIL NIL

case of self-
acquired property

Cost of property NIL NIL NIL NIL NIL NIL

(in case of
purchase) at the
time of purchase

Any investment on NIL NIL NIL NIL NIL NIL

the land by way of
development,
construction etc.
"'.,
Approximate NIL NIL NIL NIL NIL NIL
current market
value

(v) Others( such as NIL NIL NIL NIL NIL NIL

interest in
property)

FORIV' P [5..~';-~tal of current NIL NIL NIL NIL NIL NIL

~
NO!h'" t--
<>~ " '.
arket value of
to(v) above
 11

(8) I give herein below the details of liabilities / dues to public financial
Institutions and Government:

Description Self Spouse HUF Dependent- Dependent-2 Dependent-

f'0~ _'"
o .~ Dr'. .0
.~
I 3
/p .•' ~-<', ?
""'l " ','
"'"I
~,--:;._
'-7
,._J, "1
~ .
-
c ~
"',.. , ", :y-:--. '-~~; .....
o c:» .• -,
1;' ~I
. <:4",,1',.'"
\'., ."

~*}/
.,. r~_·-. -...'-!' "

.<.t,·~. ',.~

.....'.~~ r., ".11)\ "-'/

'-'.:.::.:::~-;.::.. (i)
'C'f

Loan or dues NIL NIL NIL NIL NIL NIL

to Bank /
Financial
Institution(s)

Name of the
Bank or
Financial
Institution,
Amount
outstanding,
Nature of Loan

~ Loan or dues to NIL NIL NIL NIL NIL NIL

any other
individuals /
entity other than
mentioned
above Name(s)
Amount
outstanding,
nature of loan

Any other NIL NIL NIL NIL

liability
NIL NIL

~
Grant total of NIL NIL NIL NIL NIL NIL
pLl ~rtf liabilities
FORM
 12

(A) Has the Deponent been in occupation of

accommodation provided by the Government at any YES/NO
time during the last ten years before the date of (pl.tick the
notification of the current election? NIL appropriate
(B)If answer tot'A) above is YES, the following alternative)
declaration may be furnished namely:-
(i)The address of the Government accommodation
.................. NIL •..............
(ii)There is no dues payable in respect of above
Government accommodation, towards-
(a)rent; NIL
(b)electricity charges; NIL
(c)water charges; NIL and
(d)telephone charges as on (date) NIL

\ (iii) Dues to department NIL NIL NIL NIL' NIL NIL

dealing with
Government
transport(including
aircrafts and
helicopters'

(iv) Income Tax dues NIL NIL NIL NIL NIL NIL
Self Spouse HUF Dependent-l Dependent-2 Dependent-3
(v) GST dues NIL NIL NIL NIL NIL NIL
(vi) Municipal/Property NIL NIL NIL NIL NIL NIL
tax dues
, (vii) Any other dues NIL .NIL NIL'
t
NIL NIL NIL
(viii) Grand total of all NIL NIL NIL NIL NIL NIL
Government dues
(ix) Whether any other NIL NIL NIL NIL NIL NIL
liabilities are in
dispute, if so,
mention the
or
,I', amount involved
and the authority
~
t~O-r~
4}' ,
before which it is
pending
 13

(9) Details of Profession or occupation :

.(a) Self : Private service
(b) Spouse : Not Applicable

(9A)Details ofsource(s) of income:

(a) Self -Private service sources(event management)
(b) Spouse Not Applicable
. ',C)" AI0 c) Source of income, ifany, ofdependents Nil
"'~~

{!:i.,
J
-,(.'./, \'~.',~<f,''., ft:t: .\.,. ;~
(l , ."
f
")
ontracts with appropriate Government and any public company or
.
I ""?'\ ( : '. ':-, ~< ompames:
.?,.:-O~

\\ r: \ -, f. ~.',,?!-t( Details of contract entered by the candidate Nil.

!,~ ,~-. , ",' / '_;_/~ Details of contract entered into by the Spouse
.."~ • ) Nil .
'.'. <:' :~. \ ~~,,~.~,-(c)Details of contract entered into by the dependents Nil '"
~':.:~.;::.,;:.;..~.....
(d) Details of contract entered into by the Hindu Undivided Family or trust in
which the candidate or spouse or dependents have interest Nil .
(e) Details of contract entered into by Partnership Firms -in which candidate or
spouse or dependents are partners Nil .
(t) Details of contract entered into by private companies in which candidate or
spouse or dependents have share Nil .

(10) My Education Qualification is as under:

Diploma in Pharmacy from College of Pharmaceutical Sciences,

Mohuda, Dist:Ganjam in the year 1988

PART-B
(11) ABSTRACT OF THE DETAILS GIVEN IN (1) TO (10) OF PART-A
1. Name of the Candidate B. BISHNU PRASAD SUBUDHI,
2. Full Postal Address
At-Prem Nagar 5th Lane,
PO:Berhampur, PS:Badabazar,
Dist:Ganjam, Pin-760002, Odisha
3. Number and name of the constituency 133 Berhampur Assembly
and State. Constituency
State-Odisha
4. Name of the Political Party which set Independent
up the candidate (otherwise write
'independent)

5. Total Number of pending criminal NIL

cases

6. Total number of cases In which NIL

convicted
",-
 14

7. PAN of Year for which Total Income shown

last Income Tax
return filed

(a) Candidate AFNPB8866R 2005-06 1,50,000

~~.!...~~
c'
r,
".'/
,\,1'

'-~\
'
k',
;.'.,
-J

.
K:I~ - 1
~arried
1'1'1'
Spouse NIL NIL NIL
,
L ' ~ ,_'.
'
.::: ) la.
~::....... l%r @HUF NIL
,

:.''''...........
'-.
NIL NIL
I\{, r/
</iA
'.
(~
\ . -:/ (d) Dependents
'>~::; ~' NIL NIL NIL
8 Detailsof Assets and Liabilities(including
offshoreassets) inRupees
Description Self Spouse Dependent- Dependent- Dependent-
1 1 1
A. Moveable Assets Rs. 10,96,000.00 NIL NIL NIL NIL
(Total value)
B. Immovable asset NIL NIL NIL NIL NIL
1. Purchase price NIL NIL NIL NIL NIL
of self-
acquired
immovable
property
<,

II Development / NIL NIL NIL NIL NIL

construction
cost of
immovable
property after
purchase (if
applicable)

III Approximate NIL NIL NIL NIL NIL

current market
price (a) Self-
acquired assets
(Total value)

<
, (b)Inherited NIL
assets (Total
value)
....
•) j)\Y(" •
 I'0~ *~
15

\: _,I "_'
:" ,",'
c_"
'..,~ I
"
.f I

.'-".
J. If'

9. tiabiJijie_s;" ,.'

(i) Government NIL NIL NIL

dues(Total)

(ii) Loans from Bank, NIL NIL NIL

Financial
Institutions and
others(Total)

10. Liabilities that are under dispute

(i) Government NIL NIL NIL

dues(Total)

(ii) Loans from Bank, NIL NIL NIL

Financial
Institutions and
others(Total)

11. Highest educational qualification.

Diploma in Pharmacy from College of Pharmaceutical Sciences,
Mohuda, Dist:Ganjam in the year 1988

VERIFICATION
I, B. BISHNU PRASAD SUBUDHI, 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 there from, I further declare that:
(a) there is no case of conviction or pending case against me other than those
mentioned in item 5 and 6 of part-A and B above;
(b) I, my spouse, or my dependents do not have any assets or liability, other
than those mentioned in item-7 & 8 of Part-A and items-8, 9 and 10 of
Part-B above.
Verified at Berhampur(Gm.) this the2;-;.~~. day of March 2019
Identified ~ ~. ') J I II

~asaa(j.} .t-J\.
\ ~ ~sfi
DECl.ARATION
~1" f~ ~~vW
Ad c ~1Sa <P1 t-J\.fl-., ~_, The, deo.,-'1" c· ,~,,,, >-:e,en Ide,ntlfleD ONENT
S11- OCfl-\E ,Advocate S' .. { ...
fl-O\J Uf (.Gfi\r;:t'fo'c '~" t, -, ,. .
c'--/l,~le~ ·Il
'~,P,

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afilrm
the
aefnaf09 _'Ct3r\ ,- .' O. L --b~.
read Over
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1