1. No category

Form 26
(See Rule 4A)
AFFIDAVIT TO BE FILED BY CANDIDATE ALONGWITH NOMINATION
PAPER BEFORE THE RETURNING OFFICER FOR ELECTION TO
ASSEMBLY FROM JAGADHRI ASSEMBLY CONSTITUENCY _ 08.
PART-A
l, Shameem Khan son of Mohd. Asram Khan, aged 38 years, resident of vilage Khizri p.o.
Khizrabad, Tehsil chhachhrauli, Distt. yamuna Nagar a candidate at the above election,
do
hereby solemnly affirm and state on oath as under:
pARTy (BSp).
1)
I am a Candidate set up by BAHUJAN SAMAJ
2)
My name is enroiled in Constituency No. Og, Jagadhri, Haryana, at Serial No.
838, Part No. 17.
My contact telephone numbers arc 09912152627 and my e_mail id
[email protected] and my social media account is NlL.
4)
Sr.
Details of Permanent Account Number (pAN) and status of firing of Income Tax
Retirn:Names
PAN
No.
The financial year Total income shown
for which the last in Income Tax
income tax return Return (ln Rupees)
has been filed
1
is
Shameem Khan
Mrs. Bushra Khan
Ms. Shamaila Khan
(Minor )
Yaver Khan (Minor)
l.
i
BFWPK5286E
NIL
NIL
NIL
NIL
NIL
NIL
NIL
Net Taxable Income
NIL
NIL
NIL
NIL
nol accused of any offence punishable with imprisonment for two years or more
nding case in which a charge has been framed by the court of competent
is accused of any such offence, he shall furnish the
followrno
The following case(s) is/are pending against me in which charges have been framed
Information neport frto,r ttos
together with complete details of concerned
Police Station/Districv State
Section(s)
oi
tfre-ioncernEO-Tct(s) and
short description of the offence(s) for which
charged
Name of tne Court, Case
order taking cognizance
Court (s) which
M=nO
clate of
tranreO-na[qg
Date(s) on wnicir-ire ctrarg;(s) way were
Whether atl or any of thElroceeding-@
have been stayed by any Court(s) of
competent jurisdiction
rhe following case(s) is/are pending against me
in which cognizance
liu
by the court (other than
cases mentioned in item (i) above:_
(a)
Name of the court, C;se Na and date of
order of taking cognizance
(b)
the court has
taken cognizance, section (s) of the Act(s)
and description of the offence(s) for which
r
||c uera s
oT cases where
has been taken
N,A.
NA
cognzance taken.
(c)
@
N,A.
revision
(if any) filed against the
above
orde(s)
rs convicted and punished as aforesaid, he shall furnish
the followino
Shameem Khan
- Form 26
Page 2 of
l0
The details of cases, Section (s) of the
(a)
N.A.
concerned Act(s) and description of the
offence(s) for which convicted
(b)
Name of the Court(s), Case No. and date(s)
N.A.
of orde(s)
(c)
Punishment imposed
N.A,
(d)
Whether any appeal was/has been filed
N.A.
against the conviction order. lf so, details
and the present status of the appeal
(7)
That I give herein below the details of assets (movable and immovable etc.) of
myself, my spouse and all dependents:
A. Details of movable assets:
Note:
1 .
Note :2
Assets in Joint Name indicating the extent of joint ownership will also have to
be given.
In case of deposit/lnvestment, the details including Serial 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 oer current market value in Stock
exchange in respect of listed companies and as per books in case of nonlisted companies should be given.
Note :4.
Dependent here has the same meaning as assigned in Explanation (v) under
section 75A of the Representation of the People Act, 1951
amount
Shameem Khan
- Form 26
is to be gi!
.
in respect of
each
Page 3 of
l0
Description
S,
Self
Shameem
Khan
No
Cash in Hand
Details of deposits in Bank Accounts
(FDRs, Term Deposils and all other
types of deposits including saving
accounts)
Deposits with Financial Institutions
Non-Banking financial Companies
and Co-operative Societies and the
amount in each such deoosit
Spouse name
Mrs. Bushra
Khan
2,00,000/-
1,00,000/.
-
SB A,/c HDFC
87215300050
70
8,24,623t-
Saving lJc
The Yamuna
Nagar Central
uo-op EanK
Ltd, YNR
4.83 Lac
Details of investment in Bonds,
debentures /shares and units in
Dependent
Name
Dependent
Name
Ms. Shamaila
Khan (Minor
Dauqhter)
Yawar0 Khan
(Minor Son)
Nil
Nil
Nil
Nil
FDR _ HDFC
Bank Ltd
10,00,000/--
Nil
Nil
Nil
Nil
Nil
Nil
Nil
Nil
Nit
Nil
Nil
Nil
Car - Toyota
Innova
2009 Model
HR-71-9900
Value 6.00 L
Nil
Nil
Nil
Gold
20
Tolas
6,00,000/Others
5.00.000/-
Nil
Nil
Nil
Nil
Nil
Nil
Nil
companies/ Mutual Funds and others
and the amount
Details of investment in NSS, Postal
Saving, Insurance Policies
Investment
Instruments
&
in any Financial
in Post Office or
Insurance Comoanv
&
the amount.
Personal Loans/ advance given to
any person or entity including firm,
company, Trust etc. and other
receivable from debtors and the
amount.
Motor Vehicles/ Aircrafts/ Yachts/
Ships (Details of Make, registration
number etc. year of purchase and
amount)
- Swift
2012 Model
HR 71B - 8600
Value 4.50 L
l,4aruti
Jewellery, bullion
and
valuable
thing(s) (give details of weight and
Gold
-
5 Tolas
1,50,000r
-
-
Nil
'6,1
t$ro*
"r'I
Note:
tal Value
18,83,000/-
28,24,623t-
rJ'.'e,'
1
.
Properties in joint ownership indicating the extent of joint ownership will also
have to be indicated.
Note: 2.
ShameemKhan Form 26
Page 4 of
I0
J.
Description
Self
Shameem Khan
t.
(a)
Spouse name
Dependent
Name
Dependent
Name
Ms. Shamaila
Khan (Minor
Dauqhter)
Yawar0 Khan
(Minor Son)
NIL
NIL
NIL
NIL
NIL
NIL
Yes
NIL
NIL
NIL
NA
NIL
NIL
NIL
NA
NIL
NIL
NIL
NA
NIL
NIL
NIL
1297.38 Lac
NIL
NIL
NIL
NIL
NIL
NIL
NIL
NIL
NIL
NIL
NIL
NIL
NIL
NIL
NIL
uale ot purchase in case
of self-acquired propertv
NIL
NIL
NIL
NIL
Uost ot Land (in case of
purchase) at the time of
NIL
NIL
NIL
NIL
purchase
Any investment on the land
by way of development,
construction etc.
NIL
NIL
NIL
NIL
currenf
NIL
NIL
NIL
NIL
NIL
NIL
NIL
NIL
Not applicable
Not applicable
No
Agricultural land-Locations,
Survey number(s)-
Area (Totat measuiemEit
Mrs. Bushra
Khan
Village Khrzri,
Chhachhrauti
KhewaUkhatoni No
1141196 (Jamabandi
2008-00\
92.67 Acres
in acres)
Whether inherited propertv(Yes or No)
uare oI purcnase in case
of self-acquired property
Cost of Land (in case of
purchase) at the time of
purchase (Proportionate)
Any investment on the land
by way of development,
construction etc.
Approximate current
market value
II
Non-Agriculture
land,
locations, survey no. (s)
Area (total measurement in
Ss
ft)
Whether inherited property
(Yes or No)
Approximate
market value.
ill
Commercial
buildings,
(lncluding apartments)- -
6;
,4
v'
,49
fl
tLl
ta"l
Location
- Survey No.
Areb (total measurement in
sq.ft)
bulr:up Area (total
measurement in Sq.ft)
Whether inhented property
lyes or No)
Date of Purchase in case
of SeJf acquired propertv.
Cost of property (in case of
purchase) at the time of
purchase
Any investment on the
property by way of
development, construction
Shameem Khsn
- Form 26
Not applicable
Not applicable
Not app cable
Not applicable
Not applicable
Not applicable
Not applicable
Not applicable
Not applicable
Not applicable
t
Not
Not
applicable
applicable
Not
Not
Not
Not
applicable
applicable
Not
Not
Not
Not
applicable
applicable
Not
Not
applicable
applicable
Page 5 of
l0
etc.
Approximate current value.
IV
Residential
Buildinqs
(lncluding apartments): Location(s) -Survey No.
Not applicable
purchase)
Not
NL
NIL
NIL
App. 500 Sq.Yds
(4500 sFt )
NIL
NIL
NIL
2700 sFt.
NIL
NIL
NIL
Yes
NIL
NIL
NIL
N.A.
NIL
NIL
NIL
N,A.
NIL
NIL
NIL
NIL
NIL
NIL
NIL
25.00 Lac
NIL
NL
NIL
NIL
NIL
NIL
NIL
'1322.38 Lac
NIL
NIL
NIL
at Vill.
Khizrabad
Resi. House
at the time of
purcnase
Any investment on the land
by way of development,
construction etc.
Approximate current
market value
Others, such as interest in
vt.
Not
Dnli.e h la
Khijri, P
Area (total measurement in
sq.ft)
Built up area (Total
measurement in sq.ft)
Whether inherited property
(Yes or No)
Date of purchase in case
of self acquired propertv
uost oI property (in case of
O
lloperty
Total of the current market
value of (j) to (v) above
Not applicable
e
(8). I give here in below the details of my liabilities/over
dues to pubtic financial
institutions and government:
(Note: Please give separate detairs of name of bank, institution, entity
or individuar and
amount before each item)
Dl.
-No.
-.''lq-ri ooll'
4\-l
,i'
Description
+oan ot dues to
Self
Shameem Khan
Bank/
Financial institutjon(s)
Name of the Bank or
financial Institution, Amount
outstanding, Nature of Loan
Loan or dues to any other
individuals/entity other than
mentioned above Name(s),
outstanding;
Nature of loan.
Any other liability
Grand total of liabilities
Government dues :
Dues
departments
dealing with government
accommodation
Spouse name
Dependent
Name
Dependent
Name
Khan
Ms. hamaila
Khan (Minor
Yawar0 Khan
(Minor Son)
NIL
NIL
NIL
NIL
NIL
NIL
NIL
NIL
NIL
NIL
NIL
NIL
NIL
NIL
NIL
NIL
NIL
NIL
NIL
NIL
Mrs. Bushra
Amount
(ii)
to
Shameem Khan
- Fonn 26
rL
Page 6 of 10
Dues to department dealing
with supply of water
Dues to department dealing
with supply of electricity
Dues to department dealing
with supply of telephones/
NIL
NIL
NIL
NIL
NIL
NIL
NIL
NIL
NIL
NIL
NIL
NIL
NIL
NIL
NIL
NIL
helicopters)
Income tax dues
NIL
NIL
NIL
NIL
Wealth tax dues
NIL
NL
NIL
NIL
Service tax dues
NIL
NIL
NIL
NIL
Municipal/Property iax dues
NIL
NL
NIL
NIL
Sales Tax dues
NIL
NIL
NIL
NIL
Any other dues
NIL
NIL
NIL
NIL
Grand total of
NIL
NIL
NIL
NIL
NL
NIL
NIL
NIL
mobiles.
Dues to department dealing
with government transport
(including aircrafts and
(iii)
(iv)
all
Government dues
Whether any other liabilities
are in
dispute, if so,
mention the amt involved
and the aulhoritv pendino.
(9)
Details of profession or occupation
(a)
(b)
Self
:
Spouse
:
Agriculturist
Housewife
(10).
Metric
{-lrqrl,Zl
Shameem Khan
-
Form26
Page 7 of 10
PART
-
B
(11) ABSTRACT OF THE DETAILS
GIVEN IN (1) TO (10) OF PART-A
1.
I Name of the-andidate
SHAMEEM KHAN
Full Postal address
v rage Kntzn p.o. Khizrabad,
Chhachhrauli, Distt. yamuna Nagar
08
4.
-
Tehsil
Jagadhri, Haryana
DI{FIUJAN SAMAJ PARTY (BSP).
5.
Nil
(i)
Total number of pend-ng cases
Nil
wnere the court (s) have taken
cogntzance (other than the cases
mentioned in item (i) above)
o.
I
ot cases in which
and sentenced to
orar numoer
convicted
Nil
imprisonment for one year or more
(except for offences referred to in
sub-section (1), (2) or (3) of section 8
of Representation of the people Act,
195.1)
a
q9l,lcl
_,1'
I
.
v/l
PAN
t14
Shameem Khan
-Mrs.
Year for which last
Income Tax return
Total
filed
BFWPK5286E
NIL
NIL
Bushra
NIL
NIL
NIL
Shamaila
Khan (Minor )
NIL
NIL
NIL
NIL
NIL
NIL
Khan
Ms.
Yaver
Khan
(Minor)
income
snown
I
,
Shameem Khan
- Form 26
Page 8 of
I0
8.
Details of Assets and Liabilities in Ruoees
Description
Self
Shameem
Khan
Moveable Asset
Spouse
name
Dependent
Name
Mrs. Bushra
Khan
Dependent
Name
Ms. hamaila
Khan (Minor
Daughter)
Yawar0
Khan
(Minor
Son)
18.83 Lac
28.24 Lac
Nil
Nil
Nil
Nil
Nil
Nil
Nil
Nil
Nil
Nil
Nit
Nil
Nil
Nil
1322.38
Nil
NiI
Nil
lmmovable Assets
B
Purchase Price of self
acquired immovable property
Development/ construction
cost of immovable property
after purchase (if applicable)
t
Approximate current market
pflce
(a) Self
acquired
assets
(Total value)
(b)
Inherited assets (Total
varue)
I
Lac
Liabilities
Government dues (Total)
Nrl
Nil
Nil
Nil
Loans from Bank, Financial
Nil
Nil
Nil
Nil
Nil
Nil
Nil
Nil
Nil
Nil
Nil
Nil
Nil
Nil
Nil
Nil
Institutions and others (Total)
Liabilities that are
under dispute
10
(i) covernment dues (Total
)
(ii) Loans from Banks, Fls &
others (Total)
11. Hlghe6t.Educational Quatificationi
(Give delails of highest School/Univ ersity education mentioning the full form of
the
cert
ma/degree course, nal ne of the School/University and the year in which
, o-./, the
completed)
.r{
I
I
'<'
I
ai:,
-.4
' .''/ Xfte.*
Shameem Khan
ilF-
/-/
-
/t
\
Form 26
Page 9 of
'10
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; 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 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.
v
piroro'l
Glarl ^,.
,:-
--.,
DEPONENT
,tt ]
anl
Shameem Khan
- Form 26
Page
l0 of l0