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FORM 28
(See rule 4)
NOMINATION PAP
Election to the Legislative Assembly o W*t ate)

(, t",

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 trgislative Assembly from
Irre..2.!.5..(lhti.+a..5.(......Assembtv Consrituencv.
Candidate's"-nam
"......P..Aa.th*...P-f*.1.1n....Q-.m.....................Father's/morhecs/hus,bondls
"*r"..1--xtq..!l.t+ttna.ghon/u*.b*tis
postal address.. .y.ill.:f .P.q.:.. R*m.chdt...P.!.:.. t(a'*i
.Lnt..:....P-.t*.fu-.tlghl*lel*.................................Hi, name is
entered sr. at
No......24....in part No.....t.?..2..of the electoral rolt tor ...2.t.5...Kfoinn......$.t,......Assembly
constituencv.
Mv name is Swa, kwn47 l) and it is entered at Sl. No. !.?-.1..L-.i" p*t
No.....13......of the electoral roll for the ...?-15,Kfui.*,!....5.C...........AssembIy constituency.

g-*-- k"'^*>G>>
Date oslotlzou
......r. '.. Siffrature of the Proposer
t......

PART II
We hereby nominate as candidat forelection to the Legislative Assembly from
the..........................................Assembly C
Candidate's name Father's/mother's/husband's
name..... ress
....His name is entered at Sl.
No in Part No................of the electoral for .Assembly
constituencv.
 We declare that we are electors of this Assembly constituency and our names are entered in
the electoral roll for this Assembly constituency as indicated below and we append our
signatures below in token ofsubscribing to this nomination: -

Particulars of the ro rs and their :llurcs

Sl.no. Elector Roll No. of Proposer Full Name Signature Date
Part No. of S.No. in that part
Electoral Roll
2 3 4 5 6
l. I
2.
3.
4.
5.
6.
7.
8.
9.
10.
N.B.- There should be ten electors of the constituency as proposers.

PART III
I, the candidate mentioned in Part I/Pa+*i (Strike out which is not applicable) assent to
this nomination and hereby declare thar
(a) I am a citizen oflndia and have not acquired the citizenship ofany foreign State;
(b) that I have completed years of age;
[STRIKE OUT c(i) OR c(ii) BELOW WHICHEVER IS NoT APPLICABLE]
(c) (i) I am set up at this election by the .4..f.'.T,..(.....purty, which is recognised
National Party/Stet€+ery in this State and that the symbol reserved for the above
party be allotted to me.
OR
(ii) I am set up at this election by the 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) (iD............. 4- (tii)........... x.*................
(d) my name and my father'Vrnethels/husbands name have been correctly spelt out
above in..........9 ne!i/?h...... (name 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 further declare that I am a memb". of tn"....f.-C-................+ +Caste/tribe which is a scheduled
* * caste/tribe of the State of.. in relation to.?-l.9..Ktryrrx(*!Olarea) 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-eleetirns being held simultaneously, to the Legislative Assembly
..N.4l..of(State)@ies. o r'

D"t"...P..$.loel?oz1 s,{,#!{",rW fi^

. Score out this paragraph, if not
.. Scorc out lhc words nol applicable.

N.B.-A 'reaognised polirical pany' m€ans a politicd parry recognised by th€ El€ction Co.rmission under the Electioo Syrnbols (R€s€wation

and AllotrEnt) Order, I 968 in dl€ State conccm€d.

PART IIIA
(To be filled by the candidate)
(l) Whether the candidate-
(i) has been convicted-
(a) ofany offence(s) under sub-section (1); or
(b) for contravention ofany law specified in sub-section (2)
of section 8 ofthe Representation ofthe People Act, l95l #es/No
(43 of l95l ); or
(ii) has been convicted for any other offence(s) for which he has been
sentenced to imprisonment for two years or more.

If the answer is "Yes", the ca nd te shall fumish the following information:

(i) Case/First informa tio report No.A.Jos. .
(ii) Police station(s).. District(s)...... . ... ... State(s)...

(iii) Section(s) of the Act(s) and brief description of the offence(s) for which
he has been convicted
(iv) Date(s) of conviction(s
(v) Court(s) which convi the candidate...
(vi) Punishment(s) imposed [indicate period of imprisonment(s) and/or quantam of
fine(s)l .
(vii) Date(s) ofrelease from pri n. ..
(viii) Was/were any appeal(s)/re ision(s) fi led against above conviction(s)......... YeVNo
(ix) Date and particulars ofthe l(s)/application(s) for revision filed ..

(x) Name of the court(s) before w ch the appeal(s)/application(s) for revision

fi led........................
(xi) Whether the said appeal(s)/app ation(s) for revision has/have been disposed of or
is/are pending. .. .
(xii) If the said appeal(s)/application(s) revision has/have been disposed of-
(a) Dare(s) ofdisposal... ... ... ...
(b) Nature oforder(s) passed
(2) Whether the Candidate is holding any office of profit under the Cov€mment oflndia or

State Government?.......... (':{esNo)

{fYes, details ofthe office held MA

(3) Whether the candidate has been declared insolvent by any Court?........... (Yes.No)
JfYes, has he been discharged from insolvency........N:4........
(4) Whether the candidate is under allegiance or adherence to any foreign country?............. (YesNo)
-lfYes, give details. t\'A
(5) Whether the candidate has been disqualified under section 8A ofthe said Act by an order of
the President?........... (YesNo)

JfYes, the period for which disqualified NA

(6) Whether the candidate was dismissed for corruption or for disloyalty while holding office
under the Govemment oflndia or the Government ofany State?............. (Y€s/No)
-lf Yes, the date of such dismissal......'I*-4........
(7) Whether the candidate has any subsisting contract(s) with the Government either in individual

capacity or by trust or partnership in which the candidate has a share fior supply ofany goods
to that Government or for execution of works undertaken by that Govemment?.......... (Yes/No)

-lfYes, with which Goyernment and details ofsubsisting contract(s)..........-N.A.......

(8) Whether the candidate is a managing agent, or manager or Secretary ofany company or
Corporation (other than a cooperative society) in the capital ofwhich the Central/ Govemment
or State Government has not less than twenty-five percent share?.............. (Yes/no)
-lfYes, with which Government and the details thereof............4i.4.........
(9) Whether the candidate has been disqualified by the Commission under section l0A ofthe said
Act.. ... . (IIes/No)
Jf yes, the date of disqualifi cation............

Place: eaaM
Date: Otlotlzl
trr',* *r,t*, fro'
Signature of the candidate
PART IV

r", .:.3.ff#.*t'/H3*ineom""'l
Serial No. ornomination pa
This nomination "slq4l4
,*^ a"tir-".!J to me at'my om"" *.Ri.dJ .. (hour) on...........|(date) by
the+candidatelprepeserlNane).(ailtatrdilaDqtZ {74
o^,"...919.1A... Return u
'Scorc out lh€ $ord nol applicable
215 Khejuri (S.C.) L.A.C.
l-

PART V
Decision of Returning Officer Accepting or Rejecting the Nomination Paper
I have examined this nomination paper in accordance with section 36 of the
Representation ofthe People Act, l95l and decide as follows:
-

Dale. Retuming Officer

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AFFIDAVIT TO BE FILED BY THE CANDIDATE ATONGWITH NOMINATION
PAPER BEFORE THE RETURNING OFFICER FOR ELECTION TO t
{dr B VE EMB E
215, KHEJURI {S.C.I CONSTITUENCY {NAME OF THE CONSTITUENCY)
4 PART-A
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'Gonr'' -,. -..&tfanrHA PRATIM DAS, **son of Late Purna chandra Das, Aged 50 years, resident of
tc./k'..-,.4Adl ' Vill. + P.O.
- Ramchak, P.S. - Khejuri, Dist. - Purba Medinipur, W.B. (mention full postal
address), a candidate at the above election, do hereby solemnly affirm and state on
t oath as under :-
(1) I am a candidate set up by All lndia Trinamool Congress (AlTc) (*+name of the
e political party)/ ++@.
T (**strike out whichever is not applicable)
My name is enrolled in 215, Khejuri (SC), WBLA (Name of the Constituency and the
tfslt. l. l{iilh state), at Serial No. 36 in Part No. 177
&r?-0.l{wlii. contact telephone number(s) is /are 9732552L50 and my e-mail id (if any) is

t rrln0n{litltd a [email protected] and my social media account(s) (if any) is / are

lc."IiEl'^F- i) Facebook Account - Partha Pratim Das

:r.*.lr}? (ii) Whatsapp Account - 9732552150

(iii) NIL

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(4) Details of Permanent Account Number (pAN)t and status of filling of lncome Tax return :

sl Names PAN The financial year for Total lncome s[dwn in

No. which the last lncome
Tax return has been -'ff:ff;?#ffilit"
fited FinancialYears
completed (as on 31n
March)
1 Self AFNPD4832P 2020-202L (i) 906820.00
\
(ii) 454,72.O0
Partha Pratim Das
(iii) 295890.00

(iv) 298640.00

(v) 248920.O0

2 Spouse AHDPD1199F NOT APPLICABTE (i) NOT APPLICABTE

(ii) NOT APPLICABTE

Lipika Das
(iii) NOT APPLICABTE

(iv) NOT APPLICABLE

(v) NOT APPIICABLE

3 HUF (lf Candidate is NOT NOT APPLICABLE (i) NOT APPLICABLE

Karta/Coparcener APPLICABLE
( ) NOT APPLICABLE

NOT APPLICABLE (iii) NOT APPTICABLE

(iv) NOT APPTICABLE

(v) NOT APPLICABLE

4 Dependent-1. NOT NOT APPIICABLE (i) NOT APPLICABLE

APPLICABLE
(ii) NOT APPLICABLE
NOT APPLICABLE
(iii) NOT APPTICABLE

(iv) NOT APPLICABLE

(v) NOT APPTICABLE

5 Dependent-2 NOT NOT APPTICABLE (i) NOT APPTICABLE

APPLICAETE
(ii) NOT APPTICABLE
NOT APPLICABLE
(iii) NOT APPIICABLE

(iv) NOT APPTICABLE

(v) NOT APPLICABLE

6 Dependent-3 NOT NOT APPLICABLE (i) NOT APPLICABLE

APPLICABTE
(ii) NOT APPLICABTE
NOT APPTICABLE
(iii) NOT APPLICABTE

(iv) NOT APPTICABTE

(v) NOT APPTICABLE

Note : lt is mandatory for PAN holder to mention PAN and in case of no PAN it should be c learly
"No PAN a llotted".
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(5) Pending criminal cases

(i) l de€lare that t

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f i) Ttre tottowing criminal cases ar" Sinaing .g.inrt ," ,

(t there ore pending criminol cases ogoinst the condidote, then tick this dlternative and score ofi
olternotive (i) above, ond give detoils of oll pending coses in the Toble Below)

Table

(a) FIR No. with name and As per Annexure As per Annexure As per Annexure
address of Police Station attached separately attached separately attached separately
concerned
(b) Case No. with Name of the As per Annexure As per Annexure As per Annexure
Co urt attached separately attached separately attached separately

(c) Section(s) of concerned As per Annexure As per Annexure As per Annexure

Acts/Codes attached separately attached separately attached separately
lnvolved
(give no. ol the section,
e,g, Sedion ..,,,, oI lPC,
etc.
(d) Brief description of As per Annexure As per Annexure As per Annexure
Offe nce attached separately attached separately attached separately

(e) Whether charges have As per Annexure As per Annexure As per Annexure
been framed (mention attached separately attached separately attached separately
YES or NO)

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(f) lf answer against (e) As per Annexure As per Annexure As per Annexure
above is YES, then give attached separately attached separately attached separately
the date on which
charges were framed

(e) Whether any Appeal/ As per Annexure As per Annexure As per Annexure
Application for revision has attached separately attached separately attached separately
been filed against the
Woceedings (Me ntion YES
or NO)

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(6) Cases of conviction

/ (i) I declare that I have not been convicted for any criminal offence. (Tick this olternotive, if the
condidote hos not been convicted ond write NOT APPLICABLE ogoinst olternotive (ii) below)

OR
(ii) I have been convicted for the offences mentioned below : NOT APPLICABTE

(if the condidote hos been convicted, then tick this olternotive ond score oIf olternotive (i) obove,
ond give detoils in the Toble below)

Table

(a) Case No.

NOT APPTICABLE NOT APPLICABLE NOT APPTICABLE

(b) Name of the Court

NOT APPLICABLE NOT APPTICABTE NOT APPLICABLE

(c) Section(s) of Acts/Codes

involved
NOT APPLICABLE NOT APPLICABLE NOT APPLICAETE
(give no. of the Section,
e.g. Section ...... of lPC,
etc.

(d) Brief description of NOT APPLICABLE NOT APPLICABTE NOT APPLICABTE

Offence for which convicted

(e) Dates of orders of conviction

NOT APPLICABI.E NOT APPLICABLE NOT APPLICAETE

(f) Punishment imposed

NOT APPLICABLE NOT APPLICABLE NOT APPLICABLE

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(e) Whether any Appeal/
has been filed against
conviction order NOT APPLICABLE NOT APPLICABLE NOT APPLICABLE
(Mention YES)

(h) lf answer to (g) above is YES,

give details and
present status of appeal NOT APPTICABLE NOT APPTICABLE NOT APPLICABLE

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(5A) I have 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).

[candidates to whom this ltem is not applicable should clearly write NOT APPLICABLE lN VIEW
OF ENTRIES lN 5(i) and 6 (i), abovel

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 ordel i.e, 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 all information in compliance of Hon'ble Supreme

Court's judgment in W.P.(C) No.536 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 movable assets :

Note : 1. Assets in joint name indicating the extent ofjoint ownership will also have to be given.

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

Note : 3. 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.

Note : 4. 'Dependent' means parents, son(s), daughter(s) of the candidate or spouse and any other
person related to be 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 : 5. Details should include the interest in or ownership of offshore assets.

Explanation - For the purpose ofthis Form, the expression "offshore assets" includes, details of all
deposits or investments in Foreign banks and any other body or institution abroad, and details of all
assets and liabilities in foreign countries.

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st. Description Self Spouse HUT Dependent-1 Dependent.2 Dependent.3

No.

(i) Cash in hand Rs. 19000.00 NO]APPI.ICABLE NOT NOT NOTAPPUCABTE NOTAPPTICABTE

APPTICABLE APPI.ICABI.E

(ii) Details of Deposit in Bank UBI NOTAPPI.ICABLE NOT NOT NOTAPPI.ICABLE NOT APPLICABTE

accounts (FRDs, Term Amount - APPLICABLE APPtICABtt

Rs.18149.01
Deposits and all other
types of deposits including HOFC
saving accounts) Deposits Amount -
with Financial lnstitutions, Rs.33349.00

Non-Banking Financial
Balageria C.c.B.
Companies and Co- Amount -
operative societies and Rs.77000.00
the amount in each such
SBI (Election)
deposit.
Amount -
Rs. 50000.00
(iii) Details of investment in NOT APPUCABI.E NOTAPPUCAB[E NOT NOT NOTAPPLICABI.E NOTAPPIICABLE
APPTICABTE APPTICABTE
Bonds, debentures/shares
and units in companies/
Mutual Funds and others
and the amount.
(iv) of investment in
Details Ltc NOT APPLICABI.E NOT NOT NOT APPtICAEI.E NOTAPPTICABLE

NSS, Postal Savings, Amount - APPUCABI.E APPI.ICABI.E

Rs.139228.00
lnsurance Policies and Premium
lnvestment any in Deposit
Financial lnstruments in (Total)
Post Office Or lnsurance
Company and the amount
(v) Personal loans/advance NOTAPPTICAEU NOTAPPLICABTE NOT NOT NOTAPPTICABI.E NOTAPPI,ICABI.E
APPI.ICABI.E APPLICABLE
given to any person or
entity including firm
Company, Trust etc. and
Other receivables from
debtors and the amount
(vi) Motor Vehicles/Aircraft s Maruti I,{OT APPTICABI.E NOT t{07 NOT APPI.ICABI.E NOTAPPI.ICABTE

Zypsee APPI-ICABI-E APPLICABTE

/Yachts/Ships(details of
Make Reglstration No. etc. sale agree
Year of Purchase and done
amount)
(vii) Jewellery, bullion and Gold 20 gm. NOTAPPTICABLE NOT NOT NOT APPTICABLE NOT APPLICASI.T

Rs.100000.00 APPI.ICABTE APPLICABLE

Valuable thing (give details
of weight and value)
(viii) Any other assets such as NOTAPPTICABTT NOTAPPLICABIT NOT NOT NOTAPPI.ICABTE NOT APPLICASI.E

APPI.ICABI.E APPI.ICABLE
value of Claims/interest
(ix) Gross Total Value Rs.436726.00 NOT APPI.ICABTE NOT NOI NOT APPTICAETE NOT APPTICABTE
APPTICABTT APPTICABI.E

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B. Details of immovable assets :

Note :1 Properties in joint ownership indicating the extent ofjoint ownership will also have to be
indicated.

Note :2 Each land or building or apartment should be mentioned separately in this format.

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

sr. Description Self Spouse HUF Dependent-1 Dependent-2 Dependent-3
No.
(i) Asricultural Land NOT NOT NOT NOT APPLICABLT NOT APPLICASIE
Ramdrak APPUCABLE APPUCABI,T APPUCASI.T
.lL No, - 30
Location(s) Plor No. - 1500
Survey number(s)
Area (Total measurement 5 decimal NOT t{oT NOT NOTAPPTICABTE NOTAPPtICAEI,E

ln acres) APPTICABE APPI.ICABTE APPI.ICABI.E

Whether inherited YE5 NOT N0l NOT NOT APPTICABLE NOT APPLICAETT

Property (Yes or No) APPI,ICABTE APPUCAStt APPTICABTE

Date of purchase in case of NOI NOT NOT t{07 NOT APPTICASI.E NOIAPPUCABI,T

Self acquired property APPI.ICAELE APPTICABI.E APPTICABLE APPLICABLE

Cost of Land (in case of NOT NOT NOT NOT NOT APPLICABI,E NOTAPPI.ICABTE

purchase) at the time of APPUCAELE APPI.ICABI.E APPTICASTT APPLICABLE

purchase
Any lnvestment on the NOT NOT NOT NOT NOT APPLICABLT NOTAPPI.ICABLE

land by way of APPTICABTE APPLICAELT APPLICAEI.T APPJ.ICABLT

development,
construction etc.
Approximate Current Rs.300000.00 OT NOT t{07 NOT APPLICABLT NOT APPLICAEI.E

Market value APPUCABU APPTICABLI APPUCABI.E

(ii) Non-Agricultural Land t{oT NOT NOT NOT APPUCAELT NOT APPLICABU
Mouza-Sarlpur APPIJCABI.E APPTICAStt APPTICAETE

Location(s)
JL No. -92
Plot No. - 557
Survey number(s)
Area (Total measurement 2838 sqft. t{07 NOT t{oT NOT APPI,ICAEI.E NOTAPPUCABI.E

in sq.ft.) APPTICABI.E APPUCASI.T APPUCASTE

Whether NO NOT NOT t]0T NOT APPtICASI.E NOTAPPI.ICABTE

inherited property APPt-tCAEtt APPTICABTE APPUCABLE

(Yes or No)
Date of purchase in case of osltolzotT NOT NOT NOT NOT APPLICASI.E NOT APPI,ICABLE

self acquired property osl06l2o1a APPI.ICABI.E APPI.ICABI.T APPTICABI.E

Cost of Land (in case of Rs.1200000.00 NOT NOT NOT NOTAPPLICAETE I'1OT APPI.ICABTE

purchase) at the time of APPI.ICAEI.E APPIICABI,E APPLICAELE

purchase
Any lnvestment on the NOT NOT NOT NOT NOI APPLICABI.E I.IOTAPPTICABLE

land APPIICTBTT APPUCABLT APPLICABI,E APPLICABTE

by way of development,
construction etc. I

Approximate Current Rs.1800000.00 NOT NOT NOT NOT APPLICASLE NOT APPTICABLT

market Value APPI.ICABTE APPUCABI.E APPI.ICABTE

(iii) Commercial Buildinss tl0T NOT NOT NOT NOI APPI.ICABI.E NOT APPUCABTE
A9PUCAEI.I APPTICABU ApPUCAStt APPLICABTE
(including apartments)
- Location(s)
- Survey number(s)

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Area (Total NOT t{07 0r iloT NOTAPPUCABI.E I,{OTAPPTICAETE

APPLICABI.E APPI.ICABI.E APPUCASI.E APPUCABII

measurement
tn .ft
Built up Area (Total NOT 0T NOT NOT NOTAPPTICAELE t{0TAPPUCAEU
APPLICABI.E APPTICABLE APPUCABTE APPUCASI-T
measurement in sq.ft.)
whether NOT t{07 NOT NOT NOT APPI.ICABTI NOT APPLICAETE

APPTICABU APPIICASU APPUCABII APPUCABI-T

inherited property
(Yes or No)
Date of purchase in NOT NOT ft07 NOT NOT APPTICAETE NOTAPPTICAELE

APPUCAELI APPIICAEI.E APPUCABI-E APPUCAELE

case of
Self acquired property
Cost of Property NOT NOT l,lOT NOT NOT APPLICAEI,E t{OT APPI.ICABIE
APPIICASLT APPUCABI.E APPUCABI,E APP!ICABtE
(in case of
purchase) at the time of
Purchase
Any lnvestment on the NOT APPUCAEII t{07 l,l0T NOT NOT APPUCASI-E NOTAPPTICABTT
APPUCABII APPI.ICABI.E APPTICABI.E
Property by way of
development,
construction etc.
Approximate Current NOTAPPtICAEI.E NOT NOT NOT NOT APPLICABI.E NOT APPTICAELT

APPTICABTE APPLICAETE APPLICAELE

market
Value
(iv) Residential Buildinss
Moura -Saripur
(including apartments) 2 storied
Location(s) Building N0I t{07 NOT NOTAPPUCABTE NOTAPPTICAELE

Jl No. - 92 APPLICABLI APPLICABI"E APPLICABLT

Survey number(s) Plot No. - 667
Area 2000 sq. ft. NOT NOT NOT NOTAPPUCABLE NOT APPLICABLT

APPLICAEIE APPLICAEI.E APPTICABLE

(Total measurement in
sq.ft.)
Build up Area (Total 2000 rq.ft. NOI NOT NOT NOTAPPTICABTE r./ 0T APPl.lcAELt
APPLICABLT APPLICABTE APPLICABLE
Measurement in sq.ft.)
Whether NO t{07 NOT NOT NOT APPLICASTT NOT APPTICAELT
APPUCAEU
inherited property APPLICAEI.E APPTICABLT

(Yes or No)
Date of purchase in case NO 0T NOT NOT NOTAPPUCABI,I NOT APPLICABLT

APPUCAEI.E APPUCABLE APPUCAEI.E

of Self acquired
property
Cost of Property Rs.40oo0oo.0o NOT NOT 0T NOT APPTICABLT NOT APPUCABIE

APPLICAELT APPLICABLT APPI.ICABI,t

(in case of I

purchase) at the time of

purchase
Any lnvestment on the NOI APPLICABI.E N0I NOT NOT NOTAPPLICAELT NOT APPTICAELT

APPLICABLE APPLICABI.E APPLICASLE

land by way of
development,
construction etc.
Approximate Rs.4000000.00 NOT NOT NOT NOT APPTICABI,E NOT APPLICAETE

APPtICAEtI APPUCABI.E APPTICABTE

Current market Value

(v) others (such as interest l'/07 NOT t{oT NOT NOT APPI.ICAEI.E NOTAPPTICABU
APPUCABI.E APPI.ICABI.E APPUCABI.E APPTICABI.E
in property)'
(vl) Total of current market Rs.6100000.00 NOT NOT NOT NOT APPI.ICAETT NOT APPi.ICABTE

APPTICABTE
value of (i)to (v) above APPTICABI.E APPI.ICABTE

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(8) I give herein below the details of liabilities / dues to Public Financial lnstitutions and
Government:
lNote; please give separate details of name of Bank, institution, entity or individual and amount before each iteml

st. Description self Spous€ HUT Dependent-1 oependent 2 Dependent-3

No.
(i) Loan or dues to Bank /
Financial lnstitutions(s)
NOT NOT APPLICABI.E NOT NOT APPLICABI.E NOT
Name of Bank or Balagerla C.C. APPI.ICABI.E
APPTICIBI.E APPUCAEI.E
Financial lnstitution, Eank
Amount outstanding, ContaiBr.
Rs.4ooflno.0O
Nature of Loan
Loan or dues to any
other individual/entity
other than mentioned ti0T NOTAPPTICAELT NOT NOT APPI.ICABLE NOT
above, TIOT APPUCABU APPI.ICABI.E
APPUCAEU APPUCAEII

Name (s) Amount

Outstanding,
nature of loan
Any other liability NOT APPTICABTE NOT NOT APPLICABLT NOT NOT APPLICABI.E NOT
APPTICAELE APPLICABLE APPTICABLI

Grand Total of Rs.4000000.00 t{07 NOT APPLICABLE NOT NOI APPTICABI.E NOT
APPTICABI.T APPLICASLE APPTICAELE
liabilities

(ii) Government Dues (A) Has the Oeponent been in occupation of accommodation YEs/ /N0
provided by the Government at any time durint the lart ten
years, before the date of notitication ofthe current election? lPl.tickthe
Dues to departments dealing opptopriote
with Government (B) lfanswer to (A) above is YES, the followint declaration may oltehotive)
accommodation be furnished namely r

(i) Th€ address of the Government accommodation

NOT APPI.ICABLE

(ii) There is not dues payable in respect of above Government

accommodation, towards -
(a) rent; NOT APPLICABLE

(b) electricity chartes ; NOT APPIICABIE

(c) water charges ; and NOT APPLICABLE

(d)telephone €harge5 as on NoTAPPLICABLE (date)

[the date should be the last date ol the third month prlor to the
month in which the election is notified or any date thereafterl

-
Note 'Ng Dues Certificate' from the agencies cgncerned in
respect of rent, electricity charges, water charges and telephone
charges for the above
Government accommodation should be submitted.
(iii) Dues to depa rtment dealing
with Government transport NOT APPI.ICABTE NOT APPLICAEU

(including aircrafts and

helicopters)

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Self Spouse HUF Dependent-1 Dependent-2 Dependent.3

(ir) lncome tax dues NOT NOT NOTAPPTICABLI NOT NOT APPUCAEU NOTAPPI.ICABTE

APPUCAEtt APPI,ICABU APPTICABTE

(v) GST Dues NOT NOT I{OIAPPUCABTE NOT NOT APPTICAELI I.IOT APPI,ICABU

APPTICABI.I APPUCABI.E APPI.ICABI.E

(vi) Municipal/Property tax NOT NOT I{OT APPLICABI,E NOT NOT APPI.ICAELT NOT APPLICABTE

APPTICABI.E APPTICABTE APPI.ICABI.E

Dues
(vii) Any other dues NOT NOT NOTAPPUCABTE NOT NOTAPPI,ICABTE NOTAPPI.ICAEI.E
APPLICAEI,t APPLICABLT APPLICABLE

(viii) Grand total of all iroT NOT NOIAPPUCAEIE NOT I{OTAPPi.ICABLE NOTAPPI.ICAETE
APPTICABI.E APPUCAEI,E APPLICAEI,E
Government dues
(ix) Whether any
other 0T NOT NOT APPUCASTE NOT NOTAPPLICAETE I'/OT APPI,ICABTE

APPI.ICABI.E APPLICABLT APPI.ICABI,E

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 - Medical Practitioner

(b) Spouse - House wife

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

-
(a) Self Private Practice
(b) Spouse - NOT APPLICABLE
(c) Sources of income, if any, of dependents, NOT APPLICABLE

(98) Contracts with appropriate Government and any public company or companies
(a) details of contracts entered by the candidate NOT APPLICABLE

(b) details of contracts entered into by spouse NOT APPLICABLE

(c) details of contracts entered into by dependents NoT APPLICABLE

(d) details of contracts entered into by Hindu Undivided Family or trust in which the 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

(f) details of contacts, entered into by private companies in which candidate or spouse or
dependents have share NOT APPLICABLE

(10) My educational qualification is as under :

B.Sc. (Vidyasagar University) - 1990, MBBS (Calcutta University) - 1996

/ University education mentioning the full form of the certificate /

(Give details of highest School
diploma / degree course, name of the School / College / University and the year in which the
course was completed.)

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 11

PART - B

(11) ABSTRACT OF THE DETAILS GIVEN IN (1) TO (10} OF PART -A :

1 Name of the Candidate Partha Pratim Das

2. Full postal address Vill. + P.O. - Ramchak, P.S. - Khejuri,
Dist. - Purba Medinipur, W.B.
3. Number and name of the constituency and State 215, Kheiuri (SC), W.B.
4 Name of the Political party which set up the All lndia Trinamool Congress (AITC)
candidate (otherwise write'lndependent')
5 Total number of pending criminal cases 10 (Ten)
6 Total number of cases in which convicted NIL
7 PAN of Year for which last Total lncome Shown
lncome Tax Return filed
(a) candidate : AFNPD4832P 2020 - 202t 906820.00
(b) Spouse : AHDPD1199F NOT APPLICABLE NOT APPLICABLE
(c) HUF NOT APPLICABLE NOT APPLICABLE NOT APPLICABLE
(d)Dependent NOT APPTICABLE NOT APPLICABLE NOT APPLICABLE
8 Details of Assets and Liabilities (including offshore assets) in rupees
Description 5elf Spouse HUF Dependent-1 Dependent-2 Dependent-3
A. Movable Assets 436726.OO NOT NOT NOT NOT NOT

(Total value) APPTICABTE APPI.ICABI.E APPI.ICAELE APPTICABI.E APPI.ICABTE

B lmmovable Asset 6100000.00 NOT NOT NOT NOT NOT

APPLICABI.E APPLICTBLE APPTICABLE APPI.ICABTE APPI.ICABLE

I Purchase Price of self-acquired 1800000.00 NOT NOT NOT NOT NOT

lmmovable Property. APPI-ICAB[E APPLICABLE APPTICABLE APPIICABLE APPI-ICABtE

Development/construction 4000000.00 NOT NOT NOT NOT NOT

cost of immovable property APPI.ICABLE APPLICABLE APPI-ICABI-E APPI.ICAELE APPTICABLT

after purchase (if applicable)

t Approximate Current Market
Price of -
- NOT NOT NOT NOT
(a) Self acquired asset NOT
s800000.00
APPI.ICABI.E APPI.ICAI,BTE APPLICABTE APPLICABI.E
(TotalValue) APPI,ICABLE

(b) lnherited asset 300000.(x)

(TotalValue)
9 Liabilities

tU Government Dues N0I NOT NOT NOT NOT NOT

(Total) APPI.ICAELE APPLICABLE APPI,ICABI,E APPI.ICABI.E APPI,ICABIE APPI.ICABTE

(ii) Loans from Bank, financial 4000000.00 N0I NOT NOT NOT NOT

lnstitutions and Others (Total) APPTICAELE APPTICABI-E APPI,ICABI.E APPLICABLE APPLICABTE

10 Liabilities that are under dispute

(i) Government Dues NOT NOT NOT NOT NOT NOT

(Total) APPuCtStE APPTICABI.T APPIICAB[E APPI.ICABTE APPLICABLE APPI.ICABI,E

(ii) Loans from Bank, Financial N0I NOT NOT NOT NOT NOT

lnstitutions and Others (Total) APPI-ICA8I.E APPIICAEI,E APPI,ICABI,E APPI.ICABI-E APPLICABTE APPLICABI.E

11. Highest educational qualification : I

B.Sc. (Vidyasagar University) - 1990, MBBS (Calcutta University) - 1996

(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.)

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 72

l? ile rn 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 part of it is false and nothing
material has been concealed there form. 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) 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 items 8,9 and 10 of Part B above.

Verified at contai tnis tfre .......7.4.... day of March, 2021

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DEPONENT

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Note ; 1 Affidavit should be filed latest by 3.00 PM on the last date of filing nomitetigpsr,/.f cln aDu r ; E &.i/,
i

Note : 2 Affidavit should be sworn before an Oath Commissloner or Magistrate of the Flrst class or
before a Notary Public.

Note : 3 All columns should be filled up and no column to be left blank. lf there is no information to
furnish in respect of any item, either "Nil" or "Not applicable", as the case 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 swom.
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 13
Ane,r, $W k""")
t Name of the Election : GENERAL ELECTION TO THE LEGISLATIVE ASSEMBLY FOR THE STATE OF
WEST BENGAL, 2021.

Name of State / UT : WEST BENGAL

(1) Name of the Constituency - (For example) 21s-Khejuri (SC Reserve)

Name of the candidate - Mr Partha Pratim Das

Sl. No.
1 Criminal antecedents
a Nature of the offence
1. Unlawful Assembly Assault ln,ury & Criminal u/s 34L/323/sO6 t.P.C.
lntimidation
2. Unlawful Assembly Assault lnjury & Criminal uls 14e/323/37e/436/
lntimidation and set fire 427 /506 t.P.C.
3. Unlawful Assembly Assault lnjury & Criminal u ls 149 / 447 /323 /32s/ 436/
lntimidation and set fire 379/427 t.P.C.
4. Unlawful Assembly Criminal Trespass, Assault u ls r49 / 448/323 / 427 I 380 /
lnjury, Mischief, Theft & Criminal lntimidation 506 t.P.C.
5. Unlawful Assembly Criminal Trespass, Assault u / s t4e / 448/ 323 / 427 / 37 e /
lnjury, Mischief & Causing Set fire. 436/506 r.P.C.
6. Unlawful Assembly, Assault lnjury, Theft & u / s L49 / 323/ 3Zs/ 37 9 / 436 t.P.C.
Causing Set fire.
7. Subjecting a women to cruelty uls 498A /323l.P.C
8. Unlawful Assembly, Causing hurt, Attempt to u ls 149 /3021364/307 1325/
Murder & Murder, Mischief. 323 t.P.C.
9. Unlawful Assembly, Causing Hurt, Mischief, u ls t4e /323l32s/ 436/ 427 I
Set fire & Criminal lntimidation 505 t.P.C.
10. Unlawful Assembly, Assault lnjury, Theft & uls t48lL49/323/3791
Criminal lndimidation 505 l.P.C.
b. Case No.
1. Khejuri P.S.4t/tL No.205/11
G.R.
2. Khejuri P.S. 178/2009 G.R. No.518/2009
3. Khejuri P.S. 197110 G.R. No. 1024/10
ol nt 4. Khejuri P.S.36/2009 G.R. No. 113/2009
?0t1 5. Khejuri P.S. L77 log G.R. No.517109
6. Khejuri P.S. L79/O9 G.R. No.519/09
7. Khejuri P.S. 166/18 G.R. No. 1113/18
8. Contai P.5. !97 /!O G.R. No.752110
9. Khejuri P.S. 182/2009 G.R. No.52212009
10. Khejuri P.5.63/2L G.R. No.394/21
c. Name of the Court
1. contaiJudicial Magistrate 1't court
2. Contai A.C.J.M. Court
s \ 3. Contai A.C.J.M. Court
4. Contai Judicial Magistrate 3rd court
3 \ 5. Contai A.C.J.M. Court
.l
+d sl 4 rl 6. Contai A.C.J.M. Court
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7. Contai A.C.J.M. Court
t 8. Contai A.C.J.M. Court
\ ! 9. Contai A.C..J.M. Court
t I 10. Contai A.C.J.M. Court

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d Whether charges have been framed or not (Yes / No)
1. YES
2. NO
3. NO
4. NO
5. NO
6. NO
7. YES
8. NO
9. NO
10. NO
e. Date of conviction, if any NOT APPLICAEI.E
f. Details of punishment undergone, if any NOT APPLICABLE
s Any other information required to be given NO
2 The reasons for the selection of the candidate. Selection shall be NOT APPLICABLE
with reference to the qualifications, achievements and merit of
the candidate, and not mere "winnability'' at the polls (not more
than 100 words)
3 Reasons as to why other individuals without criminal NOT APPLICABLE
antecedents could not be selected as candidates (not more than
100 words)

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