NOTARISED Kp-21-h5 MAR 2022

SI. No. ate

TIRGIRRTIRIIRICD
BHUBANESWAR
BARASSOCIATIO
DODISHA
20212022
TETE
RUPI

ECIA
CDHES
.10 Rs.10Rs.10
,INDIAG
wwAVwwM
INDIA
wwww.wwAweAww.wO W
NON JUDICIAL
wwww wwww.www.AW
KABINDRAKUMAR BARIK
8@l,3TTERIT ODISHA NOTARY, BHUBANESWAR 53AA 025763
GOVT. OF 0DISHA.IND1P

AFFIDAVIT TO BE FILED BY THE CANDIDATE ALONG WITH NOMINATION

PAPER TO THE ELECTION OFFICER/ RETURNING OFFICER FOR ELECTION
TO THE OFFICE OF

Ward No f Bhubaneswar-NAEMuaieipalityMunieipalCorporation for the

offieeof CouneiHor/Corporator!
OR
Bhubaneswar NAEMunieipalkity/ Municipal Corporation for the office of

Chairpersen/Mayor
(Strike out whichever is not applicable)

I, SAROJINI KHUNTIA, sen/daughter/wife of Tuna Swain, aged about 36 years, resident

of Plot No.963/2151, Prakruti Vihar, Baramunda, P.S-Khandagiri, Bhubaneswar-751003
Dist-Khordha, Odisha (mention full postal address), a candidate at the above election, do
ereby solemnly affirm and state on oath as under:

KABINDRA AR
NO

m Pkam a candidate set up by AAM AADMI PARTY (name of the political party)/am

KOMAR BARIK
eeptesting as-an Independent-eandidate. (strike out whoever is not applicable).

ONRegd. No.-
83/2012 Page 1 of 14

BHUBANESWAR
OFOD
BIAA
OeN 20 CO ISTRICTTREA

K H U R D AE
, e

E121722
03
FEB

NLTG,
ARL
I K ww.e w
wn

y
P1222

Soacgini khuntia
 0 5MAR 202

(2) My name is enrolled in BARAMUNDA (Name of the Ward No.50 Municipality/

Municipal Corporation), at Serial No4944in Booth No.222 Sorafini phun4ia

(if any) is
contact telephone number(s) is /are 8249256961 and my e-mail id
(3) My
media account(s) (if any) is /are.
sarojinswain@gmail.com available and my social

..NIL.....
()
i) .NIL.

and status of filing of Income tax

Details of Permanent Account
Number (PAN)
(4)
return
The Iotal Income shown in
SI. Names PAN Income Tax Return (in
financial
five
No.
year for Rupees for the last
which the Financial years
last Income- completed (as on 31
tax return March)
has been
filed
Self
NQXPS5350B NOT FILED ) N I L
(i1) NIL
(Sarojin Khuntia) (ii)| NIL
(iv) | NIL
(v)NIL
2013-2014 ( ) Rs.2,44,820.00
CJRPS2779A
Spouse 2014-2015 | (ii) |Rs.2,64,320.00
(Tuna Swain) 2016-2017 (iii)Rs.3,55,814.00
2017-2018 (iv)Rs.4,48,284.00
2018-2019 (v) Rs.4,84, 120.00
NIL
NOT FILED ) NIL
HUF (If Candidate
3. (ii) NIL
is Karta/ (ii) NIL
Coparcener) (iv) NIL
(V) NIL
No PAN NIL (i) NIL
Dependant I (ii)NIL
4. allotted
Madhusudan (ii) NIL
Mansingh(son) (iv) NIL
(v) NIL
No PAN NIL )|NL

.
Dependant 2
allotted ii) NIL
(Monalisa (iii) NIL
Mansingh(daughter) (iv) NIL

TA
KABINBRA HUMTAR
AR BARIK Page 2 of
14
(V) NIL

ONRegd. No.
83/2012 *\
OFBHRANESWAR ON
7
 05 MAR 2022

6. Dependant 3 No PAN NIL ) NIL

allotted (ii) NIL
ii) NIL
(iv) NIL
(V) NIL

PAN holder to mention PAN and in case of no PAN, it

Note: It is mandatory for
should be clearly stated 'No PAN allotted".

5) Pending criminal cases

) I declare that there is no pending criminal case against me. V

Candidate
Tick this alternative of there is no criminal case pending against the
bure
and write NOT APPLICABLE against alternative (i) below)
OR

(ii) The following criminal cases are pending against me:

the candidate, then tick this
(If there are pending criminal cases against
details of all pending
alternative and score off alternative (i) above, and give

cases in the Table below)

NOT NOT NOT
a) FIR No. with name and
APPLICABLE APPLICABLE APPLICABLE
address of Police Station
concerned NOT
Case No. with Name of NOT NOT
b) APPLICABLE APPLICABLE APPLICABLE
the Court NOT NOT
Section(s) of concerned NOT
(c) APPLICABLE APPLICABLE APPLICABLE
Acts/Codes involved
(give no. of the Section,
e.g. Section........... of
IPC,etc.) NOT NOT
Brief description of NOT
(d)
APPLICABLE APPLICABLE APPLICABLE
offence NOT NOT
Whether charges have NOT
(e) APPLICABLE | APPLICABLE APPLICABLE
been framed (mention
YES or N0) NOT
If answer against (e) NOT NOT
(1) APPLICABLE
above is YES, then give APPLICABLE | APPLICABLE

the date on which

chargeswere framed.
Whether any Appeal / NOT NOT NOT
() APPLICABLE APPLICABLE APPLICABLE
Application for revision
has been filed against

OT
KABIMNOBPA NKUMMAR3 8BAR
the proceedings
(Mention YES or NO)

Page 3 of 14

Regd. No.-
BiHNE/20o14
IND
 05 MAR 2022

Cases of conviction
(6) criminal offence y
declare that I have not been convicted for any
() I
convicted and write
candidate has not been
(Tick this alternative, if the

NOTAPPLICABLE against alternative (ii) below)

OR
mentioned below:
for the offences
(ii) I have been convicted off
alternative and score
then tick this
the candidate has been convicted,
(If
and details in the Table below)
give
alternative (i) above,

Table
NOT
NOT
Case No.
NOT
(a) APPLICABLE APPLICABLEAPPLICABLE
NOT
NOT
Name of the Court NOT APPLICABLE
(b) APPLICABLE | APPLICABLE
NOT
NOT
Sections of Acts/ Codes
NOT APPLICABLE
(c) of the
APPLICABLE | APPLICABLE

involved (give no.

Section, e.g.
Section......... of IPC,
NOT
etc).
Brief description of
NOT
APPLICABLE APPLICABLE
NOT
APPLICABLE
(d) offence for which

convicted. NOT NOT

Dates of orders of NOT
APPLICABLE APPLICABLE APPLICABLE
(e)
conviction NOT NOT
NOT
Punishment imposed APPLICABLE APPLICABLE APPLICABLE
Cindicate period of
imprisonment awarded
the fîne
and/or quantum of

imposed) NOT NOT NOT

Whether any Appeal has APPLICABLE APPLICABLE APPLICABLE
(g)
been filed against
conviction order (Mention
YES or N0)
Repeat the above

sequence in respect of
each separate case of
conviction. NOT NOT
NOT
(h) (g) above is
If a n s w e r APPLICABLE| APPLICABLE APPLICABLE
YES, give details and
present status of appeal. NOT NOT NOT
Discharged/ acquitted in
i) APPLICABLE | APPLICABLE | APPLICABLE
the cases(s)
Section ofthe Act and

VARINDTA KIMAR RA IK
Regd.
ON E3/2012No.
Page 4 of 14

BRANESWAR NDI
 05 MAR 2022

description ofthe offence.

The Court Which had NOT NOT NOT
APPLICABLE APPLICABLE APPLICABLE
taken cognizance
NOT NOT NOT
(k) Case No.
APPLICABLE APPLICABLE APPLICABLE

NOT NOT NOT

() Details of
APPLICABLE APPLICABLE APPLICABLE
Appeal/application for
revision etc. if any filed
against above order taking
cognizance. NOT
Cases(s) is/are pending NOT NOT
(m) APPLICABLE APPLICABLE APPLICABLE
against me which
cognizance Section Act
and Description of the
offence for which
cognizance. NOT
The Court Which had NOT NOT
(n) APPLICABLE APPLICABLE APPLICABLE
taken cognizance. NOT
NOT NOT
(o) Case No. APPLICABLE APPLICABLE APPLICABLE
NOT NOT NOT
(p) Details of Appeal/ APPLICABLE
APPLICABLE
Application for revision APPLICABLE
etc. if any filed against C
above order taking
cognizance. latest to be
chronological order, i.e. the
case
1. Details should be given in reverse

mentioned first and backwards in

the order of dates for the other cases.

added if required.
2. Additional sheet may be
immovable etc) of
(7) That I give herein below the details ofthe assets (movable and
spouse and all dependents:
myself,
Details of movableassets:
also have to
Note:1. Assets in joint name indicating the extent of joint ownership will
be given.
Serial Number, Amount,
Note:2. In case of deposit/Investment, the details including,
Branch are to be
date of deposit,the scheme, Name of Bank/Institution and

given.
Debentures per the current market
as value in Stock
Note:3. Value of Bonds/ Share
books in case of non-listed
Exchange in respect of listed companies and as per
companies should be given.
candidate spouse and
parents, son(s), daughter(s) of the
or
means
NONote:4. Dependent' who
related to the candidate whether by blood or marriage,

KReABINrDdRA NoRU.M-AR SARK

ON 83 /304
any other person
Page 5 of 14

RHLSANESVARLA
 05 MAR 202

of income and who are dependent on the candidate for

have no separate means

their livelihood.
in respect of each
Note:5. Details including amount is to be given separately
investment.

Note:6. Details should include the interest in or ownership.

the expression" includes, details of
Explanation,- For the purpose of this Form,
all deposits or investments;
Self HUF Depende Depen Depen
SI Description Spouse
nt- dent-2 dent-3
No. NIL NIL NIL NIL
Cash in hand Rs.1,000/ Rs.1,000/-
) Details of deposit in State Bank State Bank of NIL NIL NIL NIL
ii) India, OUAT
Bank accounts of India,
(FDRs, Term OUAT Branch,
Deposits and all Branch, BBSR, bearing
other types of BBSR, C.
bearing AVc. No.200574404
deposits including
No.3655406 47 amount of
saving account(s),
Deposits with 9498amount Rs.11,00,000/-
Financial of
Institutions, Post Rs.4,60,000/
Office/ Current
Accounts, Non-
Banking Financial
Companies and
Cooperative societies
and the amount in
eachsuch deposit. NIL NIL NIL NIL
Details of investment NIL NIL
(ii)
in Bonds,
Debentures/Shares
and units in
companies/ Mutual
Funds and others and
the amount. NIL NIL
NIL NIL NIL NIL
Details of investment
iv) in NSS, Postal
Saving, Insurance
Policies and
investment in any
Financial
instruments in Post
Office or Insurance
Company and the

amount.

KABE/2012
NARA KASNo BARIK
ON Regd.
Page 6 of 14

EANESWAY
AsEA
.
 05 MAR 2022

NIL NIL NIL NIL NIL NIL

(v) Personal
loans/advance given
to any person or

entity including firm,

company, Trust etc.
and other receivables
from debtors and the

amount. NIL NIL NIL NIL

NIL TATA
(vi) Motor Vehicles such INDIGO ECS
as Jeep, Cars, Bus,
Trucks, heavy (car) bearing
Regd. No.OD-
Vehicles (Details of
02-N-1932,
Make, Registration
number etc. year of make-2013,
year of
purchase and
amount) with
purchase 2014,
amount
approx. present
Rs.6,00,000/-,
market value
present market
according to you.
value
Rs.50,000/ NIL NIL
NIL NIL
10 grams NIL
(vii) Jewellery, Gold,
Gold Ornaments gold of
Silver and Silver Rs.50,000-
Ornaments valuable
thing(s) (give details
of weight and value)
with approx. present
market value

according to you. NIL NIL NIL

NIL NIL
Any other assets NIL
(viii) such as value of
claims/interest. Rs.5,11,000/- Rs.11,51,000/-
(ix)_ Gross Total value

assets:
(8) Details of Immovable
indicating the extent of joint ownership will
Note:1. Properties in joint ownership
also have to be indicated.
mentioned separately in this
Note:2. Each land or building or apartment should be

format.

include the interest in or ownership of assets.

Note:3. Details should
NO

ARA
KARINDRA KEMAR BARIK
Regd No.-
3/2012
Page 7 of 14

NESWARIND
 05 MAR 2022

DependeDependant Dependen
Spouse HUF
Deseription Self -2 ant-3
Sl nt-1
NIL NIL
No. NIL NIL
NIL NIL
()Agricultural
Land
Location(s)
Survey
NIL NIL
number(s) NIL NIL
NIL NIL
Area (total
measurement

NIL NIL
in acres NIL NIL
Whether NIL NIL
inherited
property NIL
(Yes or No) NIL NIL
NIL NIL
Date of NIL
purchase in
case of self-
acquired NIL
NIL NIL
property NIL
Cost of Land NIL NIL
(in case of
purchase) at
the time of
NIL NIL
purchase) NIL NIL
NIL NIL
Any
Investment on

the land by
way of
development,
construction
NIL NIL
NIL NIL
etc. NIL
Approximate NIL
Current market
NIL NIL
NIL NIL
value Dist-Puri,
Dist-Khordha,
(ii) Non- Tahasil Tahasil
Agricultural Bhubaneswar,
Krushna
Land Mouza
Location(s) Prasad,
Mouza- Ranasinghpur,
Survey Khata
number(s)
Maludkhas,
No.233/1002,
Khata
No.440/186, Plot
No.6/670/141
Plot
No.1215/2044 6, area
AcO.046
Area AcO.11
decs., Khata decimals.

No.440/275,

AR
N O Plot
No.1215/2135

/KABNGRA PAR BARK

area

Page 8 of 14
CN /2042
R
 05 MAR 2022

Ac0.010
decs., total
area Ac0.021
decimals

Dist-Khordha,
Tahasil-
Bhubaneswar,
Mouza-
Ranasinghpur
, Khata
No.233/1003,
Plot
No.8/1199,
area Ac0.008
decimals,
Khata
No.233/1011,
Plot
No.6/670/142
4, area
Ac0.037 decs,
total Areaa
AcO.045 decs. NIL NIL NIL
11108 sq.ft. 2004sq.ft. NIL
Area (Total
measurenment
insq.ft. NO NIL NIL NIL NIL
Whether NO
inherited
property
(Yes or No) Could not NIL NIL NIL NIL
Date of Could not
trace the trace the
purchase in
case of self- R.S.D. R.S.D.

acquired
property. NIL NIL NIL NIL
Cost of Land Rs.88,904 of Rs.3,50,000/-
(in case of mouza-
purchase) at Maludkhas
the time of
purchase. Rs.3,00,000/
of mouza-
Ranasinghpur
NIL NIL NIL NIL
Rs.20,00,000/ NIL
Any
Investment on

the land by
v a y of
N

QAelopment,
O

Cousuction
YABINRA PTRTMR RARIet Page 9 of 14
Regd No.
OS3/2012
BHU
ARA
 05 MAR 2022

Approximate Rs.35,00,000/ Rs.10,00,000/- NIL NIL NIL NIL

current market
value
(ii) Commercial Dist-Puri, NIL NIL NIL NIL NIL
Building Tahasil-
(including Krushna
apartments) Prasad,
-Location(s) Mouza-
-Survey Maludkhas,
number(s) Khata
No.440/186,
Plot
No.1215/2044
Area Ac0.11
decs., Khata
No.440/275,
Plot
No.1215/2135
area

Ac0.010
decs., total
area Ac0.021
decimals

NIL NIL NIL NIL

Area (total 168sq.ft. NIL
measurement

in sq.ft.) NIL NIL NIL NIL NIL

Built-up Area 8400 sq.ft.
(total
measurement

in sq.ft.) No No No No No
Whether No
inherited
property
(Yes or No) NIL NIL NIL NIL
Could not
Date of 01.06.2009 trace the
purchase in 27.01.2012
of mouza R.S.D. of
case of self-
Maludakhas mouza-
acquired
Ranasinghpur
property
Could not
trace the
R.S.D. of
mouza-

Ranasinghpur NIL NIL

Rs.3,50,000/- NIL NIL
Rs.57,904/-
Cost of Rs.31,000/
property (in
of mouza

OTAeof
h a s e ) at Maludakhas
e t n e of

ABIMDa purchdse. Page 10 of 14

Fgd. No.-ARIY
DHUR
 05 HAR 2022

NIL NIL NIL NIL

Any Rs.20 lakhs NIL
Investment on

the property by
way of
development,
construction

etc. NIL NIL NIL

Rs.35 lakhs Rs.10,00,000/- NIL
Approximate
current market

value NIL NIL

NIL NIL
Dist-Puri, NIL
iv. Residential
Buildings Tahasil-
(including Krushna
apartments): Prasad,
-Location(s) Mouza-
-Survey Maludkhas,
number(s) Khata
No.440/186,
Plot
No.1215/2044
Area Ac0.11
decs., Khata
No.440/275,
Plot
No.1215/2135

, area
Aco.010
decs., total
area Ac0.021

decimals NIL NIL

NIL NIL
8400 sq.ft. NIL
Area (Total
measurement

NIL NIL
NIL NIL
in sq.ft.) 8400 sq.ft. NIL
Built up Area

(Total
Measurement

in sq.ft.) NO
No No
No No
Whether No
inherited
property NIL
NIL NIL NIL
(Yes or No) 01.06.2009 NIL
Date of
27.01.2012
purchasein
case of self- of mouza-
Maludakhas
acquired NIL
NIL NIL
property Rs.3,50,000/- NIL
Rs.57,904/
Cost of
N O

Peperty (in Rs.31,000

Kensa of of mouza

KORRA
ADR MBARK
ON 33/.012
Arehase)at_ Maludakhas
Page 11 of 14

HURANESIVAR
 05 MAR 2022

the time of
purchase.
Rs.20 lakhs NIL NIL NIL NIL
Any NIL
Investment on
the land by
way of
development,
construction
etc. NIL NIL
Approximate Rs.35 lakhs Rs.10,00,000/- NIL NIL
current market
value NIL
Other (such as NIL NIL NIL NIL NIL
interest in
property) NIL NIL
Total of current | Rs.58,88,904/ Rs.13,50,000/- NIL NIL
(vi)
market value of
) to (v)
public financial institutions and
(9) Given herein below the details of liabilities/ dues
government: entity
of bank, institution,
(Note: Please give separate details of name
or individual and amount before each item)
Dependent-| Dependant- Dependenant-
Self Spouse HUF
SI Description
No. NIL NIL NIL NIL NIL
Loan or dues to NIL
)
Bank/Financial
Institution/s
Name of Bank or
Financial
Institution,
Amount
outstanding,
Nature of loan NIL NIL NIL NIL
Loan or dues to NIL NIL
any other

individuals/entity
other than
mentioned

above
Name(s), Amount

outstanding,
natureof loan NIL NIL NIL NIL
Any other NIL NIL
liability NIL NIL NIL
NIL NIL NIL
Grand total of

O14bilities
KARIMARA
KIN AA Page 12 of 14
FRec.lo RARK
BHX
 05 MAR 2022

(10) Details of profession or occupation:

(a) Self- Housewife

(b) Spouse- Social worker

(10A) Details ofsource (s) of income:

(a) Self- NIL

(b) Spouse- Business

(c) Source ofincome, if any, of dependents,...NIL. or companies

Contacts with appropriate Government and any public company
(1OB)
candidate... NIL **

of contracts entered by the

. . .

(a) details

entered into by spouse.... NIL....

(b) details of contracts
NIL
entered into by dependents..
. .

(c) details of contracts which the

Undivided Family or trust in
details of contracts entered into by Hindu
(d)
or dependents have
interest . . . . . .
NIL
..
candidate or spouse candidate or
Firms in which
into by Partnership
details of contracts, entered
(e)
NIL..

spouse or dependents are partners.. in which candidate

or

details of contracts, entered

into by private companies
()
have share... NIL..
spouse or dependents
as under
qualification is
(11) My educational School/College
Year of passing
Board/University
SI. Exam passed
High 2000
No. Board of Secondary | Janata
H.S.C. Education, Odisha
School, Kuhudi,
Dist-Khordha
National Institute 2016
+2 Science
National Institute of | of Open School,
2. Open Schooling,
Bhubaneswar
Bhubaneswar (continue)
Roland Institute of
B.Sc. Nursing Medical Science,
3.
Berhampur

form of the
education mentioning the full
School/University and the
details of highest of the
School/College/University
(Give course,
name
certificate/diploma/degree

c o u r s e was
completed.
which the
year in

ARAR Page 13 of
14

C
 05 MAR 202

VERIFICATION
contents of this
and declare that the
I, the deponent, above named, do hereby verify false
it is
and belief and no part of
affidavit are true and correct to the best of my knowledge
further declare that:
and nothing material has been concealed there from. I
mentioned
case against me
other than those
a) there is no case of conviction or pending

in items 5 and 6 of Part A and B above. those

not have any asset
or liability, other than
b)1, my spouse, or my dependants to

mentioned in items 7 and 8, 9 above.

Verified at Bhubaneswar on this the 5th day of March, 2022.

Witnesses
1. Hanapuya julekopewno
Cauceni khunHa
+/o-Anilkcmucer Sakoo DEPONENT

VITlage- Baremunela
PO- ena munde Colbny
PIN- 15I003
2. 16 12

BYME 1 t
4
2aceG
Ostop99
IDENTIFIED

Sampad
m a n SS
4DVOCATE, BHUBANESWAR

he ehovg name z
AR
KABINDRA KUMAR BARI
identie y NOTARY, BHUBANESWAR

A GOVT. OF ODISHA.INDIA
HNESTAR
cifivitaro thue
con'ains of..e
fhc knowicdge
i o besi of hisheriheir ***

ueief
Page 14 of 14
 5 MAR 2022
NOTARISED SI. No......neoono
wwv

URGIRINN LRIgP
BHUBANESW
BAR ASSOCATI
ODISHA
TEN
2021-2022
RUPEES
HIRGINDIA

.10 wAMA
Rs.10
DHESNV
KO,INDIA to

www.
INDIA NON JUDICIAL
U L A N E

wwwwwww www.w wwwATWW

KABINDRA KUMAR BARIK
@6l1 33tsT ODISHA NOTARY, BHUBANESWAR 53AA 025762
ODISHA.INDI BHUBANESWAR
PUBLIC,
BEFORE SRI K K
AFFIDAVIT
of Tuna Swain, resident of Plot
I, SAROJINI KHUNTIA, aged about 36 years, wife

No.963/2151, Prakruti Vihar, Baramunda, P.S-Khandagiri,

Bhubaneswar-751003, Dist
Khordha, Odisha do hereby solemnly
affirm and state as follows:
1. That, I am the deponent of this affidavit.
I have one spouse, one son and one daughter.
2 That, I do hereby declare that
3. That, this affidavit is required to be produced before the concerned authority,
Bhubaneswar for information and
Bhubaneswar Municipal Corporation,
necessary.
4. That, the facts stated above are true to the best of my knowledge and belief.

ldentified by me
SamfaS hwnaa S s &
(arcofin Rhunta
Advocate, Bhubaneswar DEPONENT

dartoJini khuntfa
DEPONENT NO
QLAgy Public, EMbaréswa
1he above name
KABINDRA KUMAR
KUMAR BARIN
BARI
identificd by Si.
Advoco, Bhube
def
adyKABINDRA KUMAR
NOTARY, BHUBANESWAR
g o2 egd. No.BARIKoVT.
GOVT. OF 0DISHA.INDI
ODISHA.
coi10 d ON 83/2012
. P.i. nd Siate on oth.. EHUANESWAR
he tontain of he affidavit ae true
ihe best of hisiher/ii:eir knowledge
elief
 RICHUBA
C T E

3 FEB2027
DA,

Sarralini khunuia st2l2