ANNEXURE – 5
FORM – III
[See Rule 7(1)]
NOMINATION PAPER
Name of the Gram Panchayat ………………………………
(Scheduled Area/ Non Scheduled Area)
Part-I
Election to the office of Sarpanch / Member……………………………… Ward
……………………………… Gram Panchayat.
Reservation status of the post………………………………………
I nominate the following as a Candidate for election to the office of Sarpanch
/ Member …………………………. Ward, …………………….. Gram Panchayat.
Full name of the candidate :
Age :
Father’s /Mother’s / Husband’s Name:
Postal Address of the candidate :
Occupation :
His / Her name is entered at serial number ……………. of …………….. Gram
Panchayat / concerned ward electoral roll.
My name is ………………………… and it is entered at serial number
……………………… of ………………………. Gram Panchayat / ……………………ward
electoral roll.
Date: Signature of the Proposer.
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Part - II
(Candidates Declaration)
I, the candidate mentioned in Part – I assent to this nomination and hereby
declare-
(a) that I have completed ……………………………….. years of age
(b) that the code of conduct prescribed by the State Election Commission
has
been read by me /read over to me and I will abide by it.
(c) that my name and my father’s / mother’s / husband’s name have been
correctly spelt out above in Telugu.
(d) that to the best of my knowledge and belief, I am qualified and not
disqualified for being chosen to fill the seat of Sarpanch/ Member of
Ward
No. ………………… of …………………….Gram Panchayat.
Signature of the candidate
Part – III
(Declaration in case of Scheduled Caste / Scheduled Tribe / Backward
Class Candidate)
I hereby declare that I am a member of the ……………………………… Caste /
Tribe/ Class which is a Scheduled Caste / Scheduled Tribe / Backward Class of the
State of Telangana in relation to …………………………… District or Area in the State.
Signature of Candidate
…..
The above declaration is solemnly affirmed before me………………… (name of
the officer in block letters) by Sri/Smt/Kum…….………………………………who is
personally known to me / who has been identified to my satisfaction by Sri/Smt/Kum
…………………………… of ………………………… (Village/Town)
Signature of the Gazetted Officer or any
officer of the Revenue Department
not below the rank of a Dy. Tahasildar.
(Seal of office) Full designation
Date
134
Part – IV
(To be filled by the Returning Officer)
Serial Number of Nomination Paper …………………………………………
This nomination paper was delivered to me at my office at …………………………
(hour) on ……………………. (date) by the candidate / proposer.
Date:
Returning Officer or
other authorized person
____________________________________________________________________
Part – V
(Decision of Returning Officer accepting or rejecting the Nomination
Paper)
I have examined this nomination in accordance with Rule 11 of TPR (Conduct
of Elections) Rules, 2018 and decide as follows
Accepted /Rejected
Reasons for Rejection
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
Date: Returning Officer
___________________________________________________________
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Part – VI
(RECEIPT FOR NOMINATION PAPER AND NOTICE FOR SCRUTINY)
(To be handed over to the person presenting the nomination paper)
Serial Number of Nomination paper…………………………………
The Nomination paper of Sri/Smt/Kum…………………………….……. a candidate
for election of Sarpanch/ Member of Ward No. ………………… of …………………….Gram
Panchayat was delivered to me at ………… (hour) on……………… (date) by
Sri/Smt/Kum ……………………………………. the candidate / proposer.
All nomination papers will be taken up for scrutiny at……..……. (hour)…..……..
on………….…… (date) at………………..……….(place).
Date: Returning Officer.
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