I, (Name) ___________,   name of father / mother / husband ___________   Age ____ Years,   Residing at ___________________________   declare by this Affidavit that,

1. I, contested the General / Bye-election of ___________ Municipal Corporation / Municipal Council / Nagar Panchayat / Zilla Parishad / Panchayat Samiti / Village Panchayat from ___ Ward / Electoral Division / Electoral College for the post of ___________ and result whereof has been declared on ___________. As per the said result, I won / lost / elected unopposed. (Strike out, which is not applicable.)
2. I / my representative have maintained true and correct election expenses for the period starting from nomination ___________ (date of nomination) till ___________ (date of declaration of result) (both inclusive); further, I have preserved supplementary evidential papers of expenses.
3. I declare that I have strictly followed all directions given in the order of the State Election Commission.
4. I have neither concealed nor retained any item in the expenses furnished by me.
5. I have truly and correctly included in my total expenses all those expenses which I have incurred by myself and the expenses incurred for me by my party and other persons.
6. I have furnished correct particulars of the funds collected by me for election in form of donations, gifts, loans, party fund etc. All such funds were paid willfully.
7. I will produce all book of accounts and original copies of receipts / bills / vouchers etc. in lieu of expenses incurred maintained by me to the Election Officer / Returning Officer as per his demand without fail and without delay.
8. I have not adopted paid news.

I state on solemn affirmation that, the information mentioned hereinabove is true and correct and I have not given any false information or concealed it.