1) Candidate set up by (Political Party Details)
2) Serial No……….in Part No……
3) Contact Details Form 26 (Rule 4a) – Photo + Notary Seal + Signature Declaration + Details

(4) Details of Permanent Account Number (PAN) and status of filing of Income tax return:

(5) Pending criminal cases
a) No pending criminal case against OR
b) The following criminal cases are pending against me:

(6) Cases of conviction

(6) A I have given full and up-to-date information to my political party regarding criminal cases

(7) details of the assets (movable and immovable etc.) of myself,
my spouse and all dependents:
7A. Details of movable assets :

(7) B. Details of Immovable assets:

(7) B – ii – Non-Agricultural Land
B – iii – Commercial Buildings

(7) B – iv – Residential Buildings

(8) liabilities/dues to public financial institutions
(i) – Loan or dues to Bank/Financial Institution(s)

(ii) Government Dues:

9 Details of profession or occupation:

10 My educational qualification is as under:

PART – B – 11 – ABSTRACT OF THE DETAILS GIVEN IN (1) TO (10) OF PART – A:

VERIFICATION