I

FORM - 26(See Rule - 4A)

DEF09E THE NOTARY Pur3L1C,

LA1<141MPU{Q AT NORTH LAk1-11MPURDate : 1813/ 20IA .

Affidavit to be filed by the candidate alongwith Nomination Paper

9

i

Before the Returning Officer for election to. TheHouse of People (name of the

House) from 09-Tezpur Parliamentary Constituency (Name of the Constituency)

Part - A

I Shri Bhupen Kumar Borah **son of Shri Bogiram Borah , aged about 43

years 4 months , resident of Vill : Bhogpur, P.O.: BhogpurChariali, Mouza :

Kherajkhat, P.S. : Narayanpur,Dist. Lakhimpur, Assam . (mention full postal address),

a candidate at the above Election, do hereby solemnly affirm and state on oath as under :-

(1) I am a candidate set up byIndian National Congress**(name of the political

party)

1) k iyoti 9fazarikaNOTARY

L*hlMpur , NIP.- 4

2

^p. I.T^ r a^t5^

(2) My name is enrolledin 109- Bihpuria L.A.C., Assam(Name of the constituency and the

State), at Serial No. 324 in Part No. 29.

(3) My contact telephone number is(M) 98540-13205and my e-mail id (if any) is

bhupenbora@gmaikcom and my social media accounts are i) bhupenborah.blogspoLin and ii)

@bhupenkborah

(4) Details of Permanent Account Number(PAN) andstatus of filing of income Tax return.

Si. Names Permanent The financial year Total income shown

No. Account Number for which the last In Income Tax(PAN) Income-tax return Return (in Rupees)

has been filed

1. Self ALOPB 1399N 2013 - 2014 Rs. 9,34,660/-

2. Spouse- AHBPB 1197R 2013 - 2014 Rs. 6,43,282/-

Dr. (Smt) Mousumi

Borgohain Borah

3. Dependent I (Pragyan) NIL Not Applicable Not Applicable

4. Dependent 2 (Rohan) NIL Not Applicable Not Applicable

5. Dependent 3 Not Applicable Not Applicable Not Applicable

(Not Applicable)

(5) I jvdam not accused of any offence(s) punishable with imprisonment for two years or more in a

pending case(s) in which a charge(s) has/have been framed by the court(s) of competent jurisdiction.

If the deponent is accused of any such offence(s) he shall furnish the following information

Not Applicable

(i) The following, case(s) is/arepending against me in which charges have been framed by the

court for an offence punishable with imprisonment for two years or more :- Not Applicable.

A Case/First Information Report No-Nos. together Not Applicable

with complete details of concerned Police

Station/District/State

B Section(s) of the concerned Act(s) and short Not Applicable

description of the offence(s) for which charged

C Name of the Court, Case No. and date of order Not Applicable

taking cognizance.

D Court(s) which framed the charge(s) Not Applicable

E Date(s) on which the charge(s) was/were framed Not Applicable

F Whether all or any of the proceedings(s) have been Not Applicable

stayed by any Court(s) of competent jurisdiction

i1lv l Z 14

(Dibya youY fazarikaNOTARY

LakhlOpur, I*.R- 4

3

(ii) The following case(s) is/are pending against me in which cognizance has been taken by the

court [other than thecases mentioned in item(i) above] :- Not Applicable

A Name of the Court, Case No. and date of order

taking cognizance

Not Applicable

B The details of cases where the court has taken Not Applicable

cognizance, section(s) of the Act (s) and description

of the offence (s) for which cognizance taken.

C Details of Appeal(s)/Application(s) for revision (if Not Applicable

any) filed against the abovg order (s)

(6) I ^en/have not been convicted of any offence(s) (other than any offence(s) referred to

in sub- section (1) or sub-section (2), or covered in sub-section (3), of section 8 of the

Representation of the People Act, 1951 (43 of 1951) and sentenced to imprisonment for one year or

more.

law : Not Applicable.

If the deponent is convicted and punished as aforesaid, he shall furnish the following

information : Not Applicable

In the following cases, I have been convicted and sentenced to imprisonment by a court of

A The details of cases, Section(s) of the of the concerned Act(s) Not Applicable

and description of the offence(s) for which convicted :blelit AN

B Name of the Court(s), Case No. and Date(s) of order(s) : cao pp

Not ApplicableC Punishment imposed :

ableliAND Whether any appeal was/has been filed against the conviction cot pp

order.

If so, details and the present status of the appeal :

Note : 2. In case of deposit/ Investment, the details including Serial Number, Amount, date of

deposit, the Scheme, Name of Bank/Institution and Branch are to be given.

Note : 3. Value of Bond/Share/Debentures as per the current market value in Stock exchange in

respect of listed companies and as per books in case of non-listed companies should be

(7) That I give herein below the details of the assets (movable and immovable etc.) of myself,

my spouse and all dependents :

A. Detailsof movable assets :

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

given.

14'LL-1Ot6yqUok xauri

NOTARYLakhiw , NLP.- 4

4

i

Note : 4 Dependent here has the same meaning as assigned in Explanation (v) under section 75 A

Note : 5

of theRepresentation of the PeopleAct, 1951.

Details including amount is to be given separately in respect of each investment.

Si.No

Description Self SpouseDr. (Smt.)Mousumi

Borgohain Borah

I Cash in hand Rs. 2,80,000/- Rs. 51,500/-

II Details of Deposits inBank accounts(FDRs, Term

Rs. 3,41,312/-at S.B.I.,Dispur.

1) Rs. 26,534/- atS.B.I., Panbazar(S.B. Account)

Deposits and all othertypes of Deposits

(S.B. Account)as on

as on 13/03/2014

including savingaccounts), Depositswith Financial

07/03/2014 2) Rs. 6,193/- atAllahabad Bank(S.B. Account)

Institutions, NonBanking FinancialCompanies andCooperative societiesand the amount ineach such deposit

as on 04/03/2014

III Details of investmentin Bonds,Debentures/sharesand units incompanies/MutualFunds and othersamount.

NIL NIL

IV Details of investmentin NSS, Postal

Rs. 8,00,000/-in LIC Policies

1.Rs. 70,000/- inN.S.C.

Saving, Insurance (Upto 2014) 2.

Polices andinvestment in any

(Premiumwise)

Rs. 6,98,976/- inLIC (SGL) as on

Financial Instrument 18.12.2013.

in Post office or 3.

Insurance Companyand the amount

Rs. 7,50,000/- inLIC Policies(Upto 2014)(Premium wise)

V Personalloans/advance givento any person orentity including firm,Company, Trust etc.and other receivablesfrom debtors and theamount.

NIL NIL

Depende Depende Dependent

nt I nt 2 3Pragyan Rohan Not

Applicable

NIL NIL NotApplicable

NIL NIL Not

a Applicable

NIL NIL NotApplicable

NIL

NIL

NIL

NIL

NotApplicable

NotApplicable

06yalyoU azanNOTARY

Lakhirru. p' e . A

5

VI Motor Vehicles/ Second hand NIL NIL NIL Not

Aircrafts/ Yachts/ Innova Applicable

Ships (details of Make 2012Make, Registration (AS-Ol/No. etc. Year of MB8001)Purchase and Year ofamount) purchase 2013

AmountRs. 8,00,000/-

VII Jewelry, bullion and 7 Tolas 12 Tolas NIL NIL Notvaluable things(s) Value Value Applicable

(give details of Rs. 75,000/- Rs. 1,15,0001-wei t and value)

VIII Any other assets such NIL NIL NIL NIL Not

as value of Claims/ Applicable

interest

IX Gross Total value Rs. 22,96,312/- Rs. 17,18,203/-

B. Details of Immovable assets :Note : 1. Properties in joint ownership indicating the extent of joint ownership will also have to be

indicated.2. Each land orbuilding or apartment should be mentioned separately in this format.

Sl. Description Self Spouse Depende-Depende- Depende-

No. DP; (Smt.) nt 1 nt 2 nt 3

Mousumi Pragyan Rohan Not

Borgohain Borah Applicable

(i) Agricultural Land Singra Village NIL NIL NIL Not

Location(s) P.P. No.- 94 Applicable

Survey number(s) Dag No. 432,453

Area (Total 1.33 Acres NIL NIL NIL Not

measurement in Applicable

acres)Whether inherited Yes NIL NIL NIL Not

property (Yes or No) Applicable

Date of purchase in Not NIL NIL NIL Not

case of self acquired applicable Applicable

property

Cost of Land (in case Not NIL NIL NIL Not

of purchase) at the applicable Applicable

time of purchase

Any Investment on Not NIL NIL NIL Not

the land by way of applicable Applicable

development,construction etc.

Approximate Current Rs. NIL NIL NIL Not

market value 1,20,000.00 Applicable

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Non-AgriculturalLandLocation(s)Survey number(s)

Area (Totalmeasurement inacres)

Whether inheritedproperty (Yes or No)

Date of purchase incase of self acquiredproperty

Cost of Laod (in caseof purchase) at thetime ofpurchase

Any Investment onthe land by way ofdevelopment,construction etc.

Approximate Currentmarket value

CommercialBuildin(includingapartments)-Location(s)

'l - urve number(s)tt6141°' XM

fyyaoNOTARY

LakhIR1fMW, NLP.- 4

Land at 1) Land at NIL NIL Not

Revenuevillage Gog

Sarusajai, GuwahatiKPP No. 366, Dag

Applica-ble

under Mouza No. 1144Ramcharaniunder AzaraRevenueCircle

2) Land atLakhimpurKPP No. 17,Dag No. 21

P.P. No. 78,Dag No. 364

3) Land atNarayanpur

and 365. KPP No. 214,Dag No. 2594) Land atNarayanpur

Dag312KPP NoI

10 ,.No. 1117, 1118,1119,1120,1121

1 Bigha 1) 03 Kathas (8520 NIL NIL Not

(14200 Sq.ft) Sq.ft.) Applica-ble

42.955 (acres) 1.7892 (acres)2) 02 Bighas 01Katha 16 Lechas87.099 (acres)3) 03 Kathas 17Lechas2.3289 (acres)4) 06 Bighas 03Kathas 03 Lechas19.965 (acres)

No No NotApplica-

ble

NotApplica-

ble

NotApplica-

ble

31.10.2012 1) 21-12-2013 Not Not Not

2) 10-10-2012 Applica- Applica- Applica-

3) 27-05-2013 ble ble ble

4127:Q5-2013Rs. 1) Rs. 39,50,000/- Not Not Not

000/-0022 2) Rs. 65,000/- Applica- Applica- Applica-,,3) Rs. 95,000/- ble ble ble

4) Rs. 6,00,000/-N NotNIL NIL Not

Applica-ble

otApplica-

bleApplica-

ble

NRs. 1) Rs. 50 ,00,000/- Not ot

00,000/-60 2) Rs. 1 ,00,000/- Applica- Applica-,3) Rs. 2,00,000/- ble ble

4) Rs. 8,00,000/-NotNIL NIL Not

Applica-ble

Applica-ble

NotApplica-

ble

NotApplica-

ble

7

Area (Total Not Not Not Not Not

measurement in s. ft.) Applicable Applicable Applicable Applicable Applicable

Built up Area (Total Not Not Not Not Not

measurement in s. ft.) Applicable Applicable Applicable Applicable Applicable

Whether inherited Not Not Not Not Not

property (Yes or No) Applicable Applicable Applicable Applicable Applicable

Date of purchase in Not Not Not Not Not

case of self acquired Applicable Applicable Applicable Applicable Applicable

propertyCost of property (in Not Not Not Not Not

case of purchase) at the Applicable Applicable Applicable Applicable Applicable

time of purchaseAny Investment on the Not Not Not Not Not

property by way of Applicable Applicable Applicable Applicable Applicable

development,construction etc.Approximate Current NIL NIL Not Not Not

market value Applicable Applicable Applicable

(iv) Residential Building Vill : At NIL NIL Not

(including apartments) Bhogpur Ghoramora, Applicable

-Location(s) Mouza : Beltola,-Survey number(s) Kherajkhat Guwahati P.P.

Dist.: No. : 42Lakhimpur, Dag No.: 113AssamP.P. No. 15Dag No.218

Area (Total 21024 sq. ft. 5760 sq. ft. NIL NIL Not

measurement in sq. ft.) Applicable

Built up Area (Total 2000 sq. ft. 3000 sq.ft. NIL NIL Not

measurement in sq. ft.) Applicable

Whether inherited No. No. Not Not Not

property or No) Applicable Applicable Applicable

Date'of purchase in 20-11-2006 16-11-2001 Not Not Not

case of self acquired Applicable Applicable Applicable

propertyCost of property (in Rs. Rs. 2,00,000/- Not Not Not

case of purchase) at the2,92,000/- Applicable Applicable Applicable

time of purchaseAny Investment on the Rs. Rs. 1,10,000/- Not Not Not

property by way of 8,08,000/- Applicable Applicable Applicable

development,construction etc.Approximate Current Rs. Rs. Not Not Not

market value 18,50,000/- 80,00,000/- Applicable Applicable Applicable

(v) Others (such as NIL NIL NIL NIL Not

interest in property)Applicable

(vi) Total of Current Rs. Rs. NIL NIL Not

Market Value of (i) to 79,70,000/- 1,41,00,000/- Applicable

v above

4 /ft ^Iutl

(Dibyq&oti eta kaNOTARY

LskhlfflWr , Iii-R.- 4

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(8) I give herein below the details of liabilities/ dues to public financial institutions and government :-(Note : Please give separate details of name of Bank, institution, entity or individual and amount for

Si. Description Self Spouse Dependent Dependent Dependent

No. Dr. (Smt.) 1 2 3Mousumi Pragyan Rohan Not

Borgohain Applicable

Borah(I) Loanor dues to Bank/ 1) Loan from ousing loan NIL NIL Not

Financial Institution (s) Assam from Applicable

Name of Bank or Financial Legislative AllahabadInstitution, Assembly Bank, Ghy-IAmount outstanding Rs. 7,16,000/- Rs. 1,84,225/-Nature of loan (Personal)

Loanor dues to any NIL Unsecured loan NIL NIL Not

individuals/ Entity other from private Applicable

than mentioned in (i) individual

above. (Sri Manoj

Name(s) Kumar Borah

Amount outstanding and others)Nature of loan Rs.24,50,000/

Any other liability NIL NIL NIL NIL NotApplicable

Grand total of liabilities Rs. Rs. NIL NIL Not

7,16,000/- 26,34,225/- Applicable

(ii) Government Dues : NIL NIL Not Not Not

Dues to departments Applicable Applicable Applicable

dealingwith governmentaccommodationDues to departments NIL NIL Not Not Not

dealing Applicable Applicable Applicable

with supply of waterDues to departments NIL NIL Not Not Not

dealing Applicable Applicable Applicable

with supply of electricityDues to departments NIL NIL Not Not Not

dealing Applicable Applicable Applicable

with supply oftelephone/ mobilesDues to departments NIL NIL Not Not Not

dealing with government Applicable Applicable Applicable

transport (includingaircrafts and helicopters)Income Tax Dues NIL NIL Not Not Not

Applicable Applicable Applicable

Wealth Tax Dues Not Not Not Not Not

Applicable Applicable Applicable Applicable Applicable

Service Tax Dues-

Not NIL Not Not Not

Applicable Applicable Applicable Applicable

Municipal/ Property Tax NIL NIL Not Not Not

Dues Applicable Applicable Applicable

Sales Tax Dues Not Not Not Not Not

Applicable Applicable Applicable Applicable Applicable

Any other dues-

NIL NIL Not Not NotApplicable Applicable Applicable

NOTARYLakhia ur , NIP.- 4

9

(iii) Grand total of all Govt.

dues

NIL NIL NotApplicable

NotApplicable

NotApplicable

(iv) Whether any other Not Not Applicable Not Not Not

liabilities are in dispute, Applicable Applicable Applicable Applicable

if so, mention theamount involved and theauthority before which itis pending.

(9) Details of profession or occupation :

a. Self: Politics (M.L.A. - 109, Bihpuria L.A.C.)

b. Spouse: Service, (Asstt. Professor, Bio-Chemistry , Guwahati Medical College

Guwahati)

(10) My educational qualification is as under: 1) H.S.L.C. in the year' 1985 from Pahumora High

School, 2) HSSLC in the year 1988 from North Lakhimpur College, Lakhimpur , 3) B.A. in the year

1991 from N.L. College, Lakhimpur , 4) M.A. in (Pol. Science) in the year 1998 from D.U.

Dibrugarh,

(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.)

PART - BVEN 1 TO (10) ABOVE

=aee candidate Sh./Smt./Kum. Bhupen Kumar Borah

2. Full postal address Vill : Bhogpur , P.O. : Bhogpur Chariali

P.S. Narayanpur, Dist . : Lakhimpur.

3. Number and Name of the constituency and 109- Bihpuria LAC under 09 Tezpur HPC,

state Assam.

4. Name of he Political party which set up the Indian National Congress.

candidate (otherwise write ` Independent')

5. (i) Total number of pending cases where Not Applicable

charges have been framed by the Court for

offences punishable with imprisonment for

two years or more

(ii) Total number of pending cases where Not Applicable

the court(s) have taken cognizance [other

than the cases mentioned in item( i) above]

¢6kaNOTARY

LBkh1wwuf , MLP.- 4

10

I

dyaiyo

6. Total Number of cases in which convicted Not Applicable

and sentenced to imprisonment for one year

or more [except for offences referred to in

sub-sections (1), (2) or (3) of section 8 of

Representation of the People Act, 1951 ]

of Year for hich last Total Income Shown

N

Income Tax return filed

: ALOPB1399N7(a)Canddiddatee 2013-14 Rs. 9,34,660.00

(b) Spouse : AHBPB I197R 2013-14 Rs. 6,43,282.00

(c) Dependents : Not Applicable Not Applicable NIL

8. Details of Assets and Liabilitiesin rupees

Description Self Spouse Depende Dependent Dependent

Smt. nt 1 2 3Mousumi Pragyan Rohan Not

Borgobain Applicable

BorahNot

A Moveable Asset Rs. Rs. NIL NILApplicable

(Total value) 22,96,312/- 17,18,203/-

B Immovable Asset NotL

I Purchase Price of Rs. Rs. NIL NI

Self-acquired 24,92,000/- 49,10,000/- Applicable

immovablem

NIL NotII Development/ Rs. Rs. NIL

ApplicableConstruction cost 8,08,000/- 1,10,000/-

of immovableproperty afterpurchase (ifapplicable)

III A roximate Current Market Price ofNIL Nota. Self - acquired Rs. Rs. NIL

Applicableassets 78,50,000/- 1,41,00,000

(Total Value)b. Inheritedassets Rs. NIL NIL NIL Not

Applicable(Total Value 1,20,000/-

bilitiesLi9. a N t Not(i) Government NIL NIL Not

Applicableo

Applicable Applicabledues (Total)

t Not Not(ii) Loan from Rs.

000/-167Rs.

225/-3426

NoApplicable Applicable Applicable

Bank, Financial ,, ,,

Institutions andothers (Total)

10. Liabilities that are under disputeNot Not

i. Government dues NIL NILNot

Applicable Applicable ApplicableTotal

N Not Notii. Loans from Bank,

otNIL NILApplicable Applicable Applicable

FinancialInstitutions andothers (Total)

NOTARYLa$fiimpur , MLR- 4

11

11. Highest educational qualification : M.A. in the year 1998 in Political Science from D.U.,

Dibrugarh

(Give details of highest school / university education mentioning the full from of the

certificate/ diploma/ degree course, name of the School/ College/ University and the year in

which the course was completed.) :

1. High School Leaving Certificate from Pahumora High School, Lakhimpur in the year

1985.

2. Higher Secondary School Leaving Certificate from N.L. College, Lakhimpur in the

year 1988

3. Bachelor of Arts fromN.L. College, Lakhimpur in the year 1991

4. Master of Arts in (Political Science) from D.U. Dibrugarh in the year 1998.

VERIFICATION

I, 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.

Verified at North Lakhimpurthis the 18th day of March 2014.

Identified by

(Smt. Tulika Hazarika)Advocate, LDBA,

North LakhimpurAdvocate

N L Bar t. - 'ion

DEPONENT

Solemnly affirmed and verified before me beingidentified by Smt. Tulika Hazarika, Lakhimpur DistrictBar Association, North Lakhimpur

^. .

NOTARY PUBLICLA HIMPUR

'Di6yajyoti 1fazati&NOTARY

Lakhln1,{aut, LP.- 4

12

Note : 1. Affidavit should be filed latest by 3.00 PM on the last date of filling nominations.

2. Affidavit should be sworn before an Oath Commissioner or Magistrate of the first Class or

before a Notary Public.

3. All columns should be filled up and no column to be left blank. If there is no information

to furnish in respect of any item, either "Nil" or "Not applicable", as the case may be, should be

mentioned.

4. The affidavit should be either typed or written legibly and neatly.

[F. No. H-I1O19(6)/2012-Leg./I]

Dr. SANJAY SINGH, Addl. Secy.

Note : The principal rules were published vide notification number S.0.89, dated the 15' April.

1961 and last amended vide notifications -

(1) number S.O.728(E), dated the 8d' May, 2007.

(2) number S.O. 425(E), dated 23rd February, 2011.