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Tru'] ld. 24041921572251 1250 PORANDLA NACAR{N
Dak:19 APR 2024. lo:oo PM LICENSED STAMPVENDOR
Lic. No. 2ll12912021
pecnp.tt ir snvlvsoN Ren.No. 2l-ll-107/2024
S/o PSIDIPA.LLI RAJAI{ALLU 3,9.89/I, REDDY COLONY,
R/O flJIVGHANDHI NAGAR, SI.JRARAM, QUTHBTJLLAPUR HANIJMAKONDA
For Whom Ph 7093345490
.r sELr **

i Form 26 :rlr
(See rule 4A)
-.t
I
I
!
AFFIDAVIT TO BE FILED BY THE CANDIDATE ALONG WITH NOMINATION PAPER
E
BEFoRE THE RETURNINC OFFICER FoR ELECTION
TO HOUSE O PE PLE K ABHA 2 21 (NAME OF THE HOUSE)
FROM 08-SECUNDERABAD (GENERAL) CONSTITUENCY (NAME OF THE CONSTITUENCY)
,,
!
re
f, pA&paf,f,f SHYAMSON, **son/ daughre#-r+ife of PAGIDIPALLI RAJAMALLU, Aged 31
years, resident of H.No. 33-l55ll, RAJIVGANDHI NAGAR, SURAM, QUTHBULLAPUR,
urpodgar-ITaLKAJGIRI, TELANGANA STATE - 500055, (mention tult postal address), a
candidate at the above election, do hereby solemnly affirm and state on oath as under:-

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1. I anrcandidate Set up by VIDUTHALAI CHIRUTHAIGAL KATCHI (*tname of the polirical parry/-anr-

-@ (++ strike out whichever is not applicable)
2. My name is enrolled in 45 - QUTHBULLAPUR ASSEMBLY CONSTITUENCY, Telangana Stare (Name of
the Constituency and the state), at Serial No. l22l in Part No. 287.
3. My contact telephone number(s) iVare 9000806754 and my email lD is -No - and my social media
account(s) (ifany) is /are
(i) WHATSAPP:9000806754.
(iD FACEBOOK: pagidipalli shamson
(iii) TWITTER : ..........NO............
4. Details of Permanent Account Number(PAN)and status of filing of Income tax retum:

Sl.No. Names PAN The financialyear for Total income

which the lasl Shown in Income
Income-tax return Tax Retum(in
has been filed Rupees) for the last
Five financial years
completed (as on
3 I "r March)
I Self NIL (D NIL
PAGIDIPALLI SIryAMSON NIL (iD NIL
CCI]PP628IIH NIL (iii) NrL
NIL (iv) NIL
NIL (v) NIL
2. Spouse- (i) NrL
UN - MARRIED
NO PAN
(iD NrL
ALLOTED
NOT APPLICABLE (iii) NrL
(iv) NIL
(v) NIL
3 HUF( ifcandidate is karta/ (i) NrL
coparcener)
( ii) NrL
NO PAN
ALLOTED
NOT APPLICABLE
(iii) NrL
(iv) NIL
(v) NIL
4 Dependentl (i) NrL

NO PAN
(ii) NrL
NOT APPLICABLE
ALI-OTED (iii) NrL
(iv) NIL
(v) NIL

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5- Dependent2 (D NIL
(iD NrL
NO PAN
ALLOTED
NOT APPLICABLE (iiD NrL
(iv) NIL
(v) NIL
6 Dependent3 (i) NrL
(ii) NrL
NO PAN
ALLOTED
NOT APPLICABLE (iiD NrL
(iv) NIL
(v) NIL
Note: It is mandatory for PAN holder to mention PAN and in case ofno PAN it should be clearly
Stated "No PAN allotted"

5. Pending Criminal Cases

(D I declare that there is no pending criminal case against me. No Pending Criminal Case

(Tick this alternative if there is no criminal case pending against the Candidate and write
NOT APPLICABLE agaiwt alternative (ii) below)
OR
( ii) The following criminal cases are pending against me: NOT APPLICABLE

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

Table
(a) First Information Report No. with name and
address of Police station concemed. NOT NOT NOT
APPLICABLE APPLICABLE APPLICABLE

(b) Case No. with the name ofthe court

NOT NOT NOT
APPLICABLE APPLICABLE APPLICABLE

( c) Section(s) of the concemed Act(s)/Codes

involved (give no ofsections, e.g. Section NOT NOT NOT
of l.P.C, etc.) APPLICABLE APPLICABLE APPLICABLE

(d) Brief description of offence

NOT NOT NOT
APPLICABLE APPLICABLE APPI,ICABLE

(e) Whether charges have been framed

NOT NOT NOT
(mention YES or NO) APPLICABLE APPLICABLE
APPLICABLE

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1t) | lfanswer againsl 1e) above is YES, then NOT NOT NOT
I give the date on which charges were APPLICABLE APPLICABLE APPLICABLE
| framed
(e) Whether any Appeal/Application for
revision has been filed against the NOT NOT NOT
proceedings (Mention )zES or NO) APPLICABLE APPLICABLE APPLICABLE

6. Cases ofConviction
(D I declare that I have not been convicted for any criminal offence. NOT COI\wICTED
AT{Y CRIMINAL OFFCENCE
(Tick this ahernative ifthere is no criminal case pending against the Candidate and write
NOT APPLICABLE against alternative (ii) below)
OR
(iD I have been convicted for the offences mentioned below: NOT APPLICABLE
(Ifthere are pending crininal cases against the candidate, then tick this altemative and
score of alternative(i) above, and gie details of all pending cases in the Table Below)

Table
(a) Case No
NOT NOT NOT
APPLICABLE APPLTCABLE APPLICABLE
(b) Name ofthe Court
NOT NOT NOT
APPLICABLE APPLICABLE APPLICABLE

(c) Section(s) ofActs/Codes involved (give no

NOT NOT NOT
ofsections, e.g. Section of I.P.C, etc.)
APPLICABLE APPI,ICABI,E APPLICABLE

(d) Brief description ofoffence for which

NOT NOT NOT
convicted
APPLICABLE APPLICABLE APPLICABLE

(e) Date of orders of conviction

NOT NOT NOT
APPLICABLE APPLICABLE APPLICABLE

(0 Punishment imposed NOT NOT NOT

APPLICABLE APPLICABLE APPLICABLE
(e) Whether any Appeal has been filed against NOT NOT NOT
conviction order (Mention lES or NO) APPLICABLE APPLICABLE APPLICABLE
(h) Ifanswer to (g) above is YES, give details NOT NOT NOT
and present status of appeal APPLICABLE APPLICABLE APPLICABLE

(6.4) I have given full and up - do -date information to my political party about all pending
Criminal cases against me and about all cases ofconviction as given paragraphs (5) and (6)

[Candidate to who this Item is not applicable should clearly write NOT APPLICABLE IN VIEW
ENTRIES IN abovel
R Y
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Not
1. Details should be entered clearly and legibly in BOLD tetters.
2. Details to be given separately for each case under different columns against each item.
3. Details should be given in reverse chronological order, i.e., the latest case to be mentioned first
and backwards in the order ofdates 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 WP (C) No.536 of 201 I .
6 That I give herein below the details ofthe assets (movable and immovable etc.) of myself, my
spouse and all dependents:

A. Details of movable assets:

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

Note: 2. In case of deposit/lnvestment, the details including Serial Number, Amount, date ofdeposit,
the scheme, Name ofBank/ Institution and Branch are to be given.

Note: 3. Value ofBonds/Share Debentures as per the current market value in Stock Exchange in
respect oflisted companies and as per books in case ofnon- listed companies should be
given

Note:4. Dependent means parents, son(s), daughter(s) ofthe candidate or spouse and any other
person related to the candidate whether by blood or marriage, who have no separate means
of in- come and who are dependent on the candidate for their livelihood.

Note: 5. Details including amount is to be given separately in respect ofeach investment.

Note:6. Details should include the interest in or ownership ofoflshore 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 ofall
assets and liabilities in foreign countries.

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S.No. Descr iption Self Spouse IItrt' DependenGl Depelldent-2 Dependent-3

(D Cash in hand NOT NOT NOT NOT NOT

Rs. 30,000/-
APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE
(ii) Details of deposits in Ir . SB A/C.
Bank accounts (FDRs. b 2897166053,
Term Deposits and all S BI BANK,
UEEDIMETLA
other types ol BRANCH,
Deposits including Rs. 2,000/-
ng accounts)
1s

inancial NOT NOT NOT NOT NOT

APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE
titutions, Non
ing Financia
panres an
tive
ieties and
ount in each
ir
(iii) Details of
investment in
Bonds,
Debentures/share
s and units NIL
NOT
APPLICABLE
NOT
APPLICABLE
NOT NOT NOT
APPLICABLE APPLICABLE APPLICABLE
in companies
/Mutual Funds and
othen and the
amount
(iv) Details of
investment in
NSS, Postal
Savings,
Insurance
Policies and
NOT NOT NOT NOT NOT
investment in any NIL APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE
Financial
instruments in
Post office or
Insurance
Company and the
amount
ry) Personal
loanVadvance given
to any person or
entity including NOT NOT NOT NOT NOT
firm, company, NIL APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE
Trust etc. arld other
receivables from
debtors and the
amount.

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(vi) Motcu-Vehicles /
Aircrafu /
Yachts
/Ships(Details of ACTIVA 3G
TS 07 BW NOT NOT NOT NOT NOT
Make,
7373 APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE
registration
Rs. 64,000
Number. etc,
Year of Purchase
and amount)
(vii) Jewellery, bullion
and valuable thing(s) NOT NOT
NIL NOT NOT NOT
(give de -tails of
APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE
weight and value)
(viii) Any other assets
such as NOT NOT NOT NOT NOT
Value of NIL APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE
claims/interest

(ix) Gross Total value NOT NOT NOT NOT NOT

Rs. 96,0001
APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE

B. Details of Immovable assets:

Note: LProperties 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 ofoffshore assests.

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

(D Agricultural tand
Location(s) Survey NOT NOT NOT NOT NOT
NIL APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE
number(s)

Area(Total
measurement NOT NOT NOT NOT NOT
NIL APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE
in acres)

Whether
inherited NOT NOT NOT NOT NOT
NIL APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE
property
(Ies or No)
Date ofpurchase in case
NOT NOT NOT NOT NOT
of self - acquired NIL APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE
property
Cost of Land (in case of
purchase)at NOT NOT NOT NOT NOT
NIL APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE
the time of
purchase

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Any Investment on the

Iand by way of
NIL NOT NOT NOT NOT NOT
development APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE
construction etc.
Approximate Current NOT NOT NOT NOT NOT
market value
NIL
APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE
(ii) Non-Aglicultural Land

Location(s)
NOT NOT NOT NOT NOT
NIL APPLICABLE APPLICABLE APPLICABLE
Survey APPLICABLE APPLICABLE

numbe(s)
Ar€a (Total
NOT NOT NOT NOT NOT
Measurement in sq.ft.
NIL APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE
Whether inherited NOT NOT NOT NOT NOT
property (Yes or No) NIL APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE

Date ofpurchase in case

NOT NOT NOT NOT NOT
ofself- acquired NIL APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE
property
Cost ofLand(incase
Ofpurchase)at the NOT NOT NOT NOT NOT
NIL APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE
time ofpurchase
Any Investment on
the land
NOT NOT NOT NOT NOT
by way of NIL APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE
development,
construction etc.
Approximate
NOT NOT NOT NOT NOT
current NIL APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE
market value
(iiD Commerc Buildines
(including
apadments)- NOT NOT NOT NOT NOT
Location(s) NIL APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE
-Survey number(s)

EfT-tar NOT NOT NOT NOT NOT

Measurement in sq.ft.) NIL APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE

Built-up Area(total NOT NOT NOT NOT NOT

NIL APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE
Measurement in fsq.ft.)
-Whethaiiherited
NOT NOT NOT NOT NOT
property NIL APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE
(Yes orNo)
Date ofpurchase in case
of NOT NOT NOT NOT NOT
self-acquired property
NIL APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE

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Cost of property (in

case of purchase) at NOT NOT NOT NOT NOT
NIL
the time of APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE
purchase
Any lnvestment on the
Property by way of NOT NOT NOT NOT NOT
development, NIL
APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE
construction etc.
Approxlmale currenr NOT NOT NOT NOT NOT
Market value NIL APPLICABLE APPLICABLE APPLICABLE APPLICABLE
APPLICABLE
(iv) Residential
Buildings
(including NOT NOT NOT NOT NOT
apartments,)-
NIL APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE
Location (s)-

Survey number(s)
Area(Total NOT NOT NOT NOT NOT
Measurement in sq. ft)
NIL APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE
Builtup Area(Total NOT NOT NOT NOT NOT
Measurement in sq.ft.) NIL APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE
Whether inherited
property NOT NOT NOT NOT NOT
NIL APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPI,ICABI,E
(Yes or No)
Date ofpurchase in
NOT NOT NOT NOT NOT
case ofself-acquired NIL APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE
property
Cost of property(in
case ofpurchase) at the NOT NOT NOT NOT NOT
NIL APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE
time of purchase

Any lnvestment on the

land by way of NOT NOT NOT NOT NOT
Development, NIL APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE
construction etc.

Approximate current
NOT NOT NOT NOT NOT
Market value NIL APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE

( ) Others (such as
NOT NOT NOT NOT NOT
NIL APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE
Interest in property)
(vi) Total ofcurrent market NOT NOT NOT NOT NOT
NIL APPLICABLE APPLICABLE APPLICABLE
value o(i) to(v) above APPLICABLE APPLICABLE

g. I give herein below the details of liabilities/dues to public financial institutions and govemment:-
(N;ote: please give separate details of name of Bank, institution, entity or individual and amount
before each item)

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pt lon Self Spouse UF endent-l pendent-2 ent-3

No.

or ues
Bank/Financial
Institution(s)
NOT NOT NOT NOT NOT
Name of Bank or NIL
APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE
Financial lnstitution
Amount outstanding
Nature of loan
or ues any
Other individuals/ entitY
other than
NOT NOT NOT NOT NOT
mentioned above. NIL APPLICAB APPLICABLE
APPLICABLE APPLICABLE APPLICABLE
Name(s), Amount
outstanding, nature of
loan
Any lity NOT
NOT NOT NOT NOT
NIL APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE

tota o liabil ES NOT NOT NOT NOT NOT

NIL APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE

Government dues: ) Has th e Dep one nt b ee n ln oc cupaIi o n of accommodation

Dues to departments dealint prov de d b th e Govemme n a any m e d url ng the lasl T e l1 9(t,n
with govemment f
years Be fo re the Da te ofNotification o Ihe Cu rren e lect o n
accommodation (Pl tick the
(B ) If ans er o ( ab ove IS Y es. the fo owr ng dec lara o n lll a v be
fumished namelY: appropriate
(D The Address ofthe Covemment accommodation: altemative)
--..-..........NOT APPLICABLE......
(ii) There is no dues payable in respect ofabove
Covemment accommodation' towards-
(a) Rent:
(b) Electricity Charges;
(c)
Water charges; and
Telephone charges as on (date)
(d)
'-
[the date should be the last date ofthe
third month
prior to the month in which the election is notified or
any date thereafier].
Note:- No dues Certificate' from the agencies concemed in respect
of
water charges and telephone charges
rent, electricity charges,
for the above Govemment accommodation should be
submitted.

iii) Dues to lng

with govemm ent transport
(including air - craft and
helicopters) NIL
NIL

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(ir) Inclrme Tax Dues NOT NOT NOT NOT

NIL NIL
APPLICABLE APPLICABLE APPLICABLE APPLICABLE
Self Spouse HUF Deponent-l Deponent-2 Deponent-3

(u) GST Dues NOT NOT NOT NOT NOT

NIL APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE
(vi) Municipal/Property Tax NOT NOT NOT NOT NOT
NIL
APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE
(vii) Any Other Dues NOT NOT NOT NOT NOT
NIL
APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE
(viii) Grand Total of all NOT NOT NOT NOT NOT
NIL APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE
(ix) Whether any other liabilities
are in dispute, ifso, mention
NOT NOT NOT NOT NOT
the amount involved and the NIL APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE
authority before which it is
pending

9. Details ofprofession or occupation:

(a) Self : Private Employee.
(b) Spouse: Un - Married.
(9A) Details ofsources of income:
(a) Self : Private Employee.
(b) Spouse : Un - Married.
(c) Sources ofincome, ifany, ofdependents: NIL

(9B) Contracts with appropriate Govertrment and any public company or companies
(a) Details of contracts entered by the candidate: NIL
(b) Details of contracts entered into by spouse : NIL
(c) Details of contracts entered into by dependents : NIL
(d) Details of contracts entered into by Hindu Undivided Family or trust in which the candidate or
spouse or dependents have interest : NIL
(e) Details of contracts, entered into Partnership Firms in which candidate or spouse or dependents are
partners: NIL
(f) Details of contracts entered into by private companies in which candidate or spouse or dependents
have share : NIL
10. My educational qualification is as under:

SSC _ZPHS - MADIRPURAM, THIRUMALAYAPALEM (IVD KHAMMAM (D) .2007.

(Give details highest School/University education mentioning the full form of the certificate/
of
diploma/degree course, narne of the SchooUCollege/University and the year in which the course was
completed.)

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$
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PART-B
(I I).ABSTRACT OF THE DETAILS GIVEN IN(I) TO (I O) OF PART.A:

I Name of the candidate Shri. PAGIDIPALLI SHYAMSON

2. Full postal address H.No. 33-155/1, RAJMANDHI NAGAR, SURAM,

QUTHBULLAPUR, MEDCHAL-MALKAJGIRI, TELANGANA
STATE - 500055.
3 Number and name oflhe constituency and O8_SECUNDERABAD (G ENERAL) CONSTITUENCY,
State TELANGANA STATE
4. Name ofthe polilical party which setup the
VIDUTHALAI CHIRUTHAIGAL KATCHI
candidate(otherwise write' Independent')
) total number ofpending Criminal cases
NIL
6
Total Number of cases in which convicted NIL
1 PAN ot 'l otal lncome
Year for which last
Shown
Income Tax Return filed
II (a)Candidate
(b)Spouse:
CG UPP6288H
NO PAN ALLOTED
NIL
NOT APPLICABLE
NIL
NOT APPLICABLE
II (C) HUF
(c)Dependents
NO PAN ALLOTED
NO PAN ALLOTED
NOT APPLICABLE
NOT APPLICABLE
NOT APPLICABLE
NOT APPLICABLE
8
Details ofAssets and Liabilities (including offshore assets) in Rupees
Description Self Spouse HUF Dependent-l Dependent-ll Dependent-lll
I 2 3 4 5 6 7 8
Moveable Assets NOT NOT NOT NOT NOT
(Total value) Rs. 96,0001 APPLICABLE
APPLICABLE APPLICABLE APPLICABLE APPLICABLE

B Immovable Asset
I Purchase ttlce
Of self-acquired NOT NOT NOT NOT NOT
immovable
NIL APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE
property
ll DevelopTenu
construcllon cost
of immovable NOT NOT NOT NOT NOT
orooertv after NIL APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE
furbhade 1if
applicable)
III Approximate
NOT NOT NOT NOT NOT
Current Market NIL APPLICABLE
APPLICABLE APPLICABLE APPLICABLE APPLICABLE
Price of-
O Nuf No'\- t{07 Nt\ Noh
lielt'-acquired
assets(Total Value)
N\L Appt r crlUt AP9\icrblc ,App\itaUt ,4?l \tc<Ua ryp\\.aUle-
NOT NOT NOT NOT NOT
(b) Inherited assets NIL APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE
(Total Value)

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9 Llabifities
l;
) (iovemment dues NOT NOT NOT NOT NOT
(Tota) NIL
APPLICABLE APPLICABLE APPLICABLE APPLICABI,E APPLICABLE
(ii) Loans from Bank
Financial NOT NOT NOT NOT NOT
NIL APPLICABLE
Institutions and APPLICABLE APPLTCABLE APPLICABLE APPLICABLE
others (Total)
10. Liabilities that are
under dispute ^lA {{,} n(A rth
(r) ^IA
Grand total of all NOT NOT NOT NOT NOT
Covemment dues NIL APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE

I
(iD Loans lrom tsank,
Financial NOT NOT NOT NOT NOT
Institutions and NIL APPLICABLE APPLICABLE APPLICABLE APPLICABLE APPLICABLE
others(Total)
ll. Highest educational qualifi cation:

ssc -zPHs-MADIRPURAM, THIRUMALAYAPALEM (l\[) KHAMMAM (D) - 2007.

(Give details of highest School / University full form of the certificate/ diploma/ degree course,
education mentioning the
name ofthe School /College/ University and the year in which the course was completed.)

VERIFICATION
I, the deponent, above named, do hereby verifo and declare that the contents of this affidavit are
true and correct to the best ofmy knowledge and belieland no part of it is false and nothing material
has been concealed therefrom. I further declare thati

a. There is no case ofconviction or pending case against me other than those

mentioned in items 5 and 6 ofPart 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 l0 ofPart B above.
k/\
verinea at....iy'..{ *24...... ,ulir rn" 2--ofu .. .. ... .day of Ott 11 $ 5*/
DEPONENT
Note: l.Affidavit should be filed latest by 3.00PM on the last day of filing nominations.
Note: 2.Affidavit should be swom before an Oath Commissioner or Magistrate ol the first Class or
before a Notary Public.
Note: 3. All columns should be filled up and no column to be left blank' If there is no
information to fumish 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 ofthe 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 it shown.

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GOPIREODY BABU
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ADVOCA
b llhlo:1&rll Strantrf Nager,
sv ErnyG0 INTXA
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