affidavit convict

ANNEXURE-A
Format of the AFFIDAVIT of the Convict

(To be filed by the Convict within ten days of the conviction)
AFFIDAVIT
I _______________________, son of/daughter of/wife of
___________________, aged about ____ years, resident of
___________________________, do hereby solemnly declare and affirm as
under:
S. No. Description Particulars

1. FIR No., date and under Section(s)
2. Name of Police Station
3. Date, time and place of offence
4. Date of conviction
5. Name of the convict
6. Father’s /Spouse’s name
7. Age
8. Gender
9. Marital status
10. Addresses: Permanent
Present
11. Contact information: Mobile
Email ID
12. Educational and professional

qualifications
13. Occupation
Signature Not Verified CRL.A. 352/2020 & CRL.A. 353/2020 Page 109 of 133
Digitally Signed
By:RAJENDER SINGH
KARKI
Signing Date:02.12.2020
19:33:41
14. Monthly income from all sources
including employment, business,
vocation, interest, investment,
income from properties, assets etc.
15. Whether you are assessed to Income

Tax? If yes, file the copy of Income
Tax Returns for the last three years.
16. Complete details of the immediate

family members (Name, age,
relation, occupation, income and
their address)
17. If the deponent is a salaried person:

(i) Designation
(ii) Name and address of the
employer
(iii) Monthly Income including the
salary, D.A., commissions/
incentives, bonus, perks etc.
18. If the deponent is self-employed:

(i) Nature of business/profession
(ii) Whether the business/profession
is carried on as an individual,
sole-proprietorship concern,
partnership concern, company,
HUF, joint family business or in
any other form.
(iii) Net monthly income
19. Income from other sources:

Agricultural Income; Rent; Interest
on bank deposits, FDRs, investments
including deposits, NSC, IVP, KVP,
Post Office schemes, PPF, loans;
Dividends; Mutual Funds; Annuities
etc.
Digitally Signed
By:RAJENDER SINGH
KARKI
19:33:41
20. Income earned by the convict during
incarceration
21. Any other income not covered above
22. Total Income Monthly
Annual
23. Immovable properties
Particulars of the immovable
properties including joint properties,
built up properties, lease hold
properties, land/ agricultural land
and investment in real estate such as
booking of plots, flats etc. in your
name or in joint names
24. Financial Assets Account Name of Current

Number Bank Balance
Particulars of all bank accounts
including Current and Savings,
Demat accounts in your name or
joint names held in the last three
years
25. Investments Particulars Current Value

FDRs, NSC, IVP, KVP, Post Office
schemes, PPF etc.; Deposits with
Government and Non-Government
entities; Stocks, shares, debentures,
bonds, units and mutual funds, etc.
26. Movable Assets Particulars Cost of acquisition

Motor Vehicles, live stock, plant and
equipment etc.
27. List of other assets not itemized

above
28. Value of total assets
Digitally Signed
By:RAJENDER SINGH
KARKI
19:33:41
DOCUMENTS TO BE FILED WITH THE AFFIDAVIT
S. No. Particulars Please Tick
Attached NA To follow
29. Aadhaar Card
30. Voter ID Card
31. PAN Card
32. Statement of Account of all bank accounts

including current, savings, DEMAT for the
last three years
33. Income Tax Return(s) of the deponent along

with the balance sheets, statement of income
and Annexures for last three years
34. Salary Slip in case of salaried persons
Declaration:
1. I solemnly declare and affirm that I have made true, accurate and
complete disclosure of my income from all sources and assets. I further
declare and affirm that I have no income and assets other than set out in this
affidavit.
2. I undertake to inform this Court immediately upon any material
change in my income and assets or any other information disclosed in this
affidavit.
3. I hereby declare that the contents of this affidavit have been duly
explained to me and have been understood by me.
4. The copies of the documents filed with the affidavit are the true copies
of the originals and I have self attested the copies after comparing them with
their originals.
Digitally Signed
By:RAJENDER SINGH
KARKI
19:33:41
5. I understand that any false statement made in this affidavit may
constitute an offence under Section 199 read with Sections 191 and 193 of
the Indian Penal Code, 1860 punishable with imprisonment up to seven
years and fine, and Section 209 of Indian Penal Code, 1860 punishable with
imprisonment up to two years and fine. I have read and understood Sections
191, 193, 199 and 209 of the Indian Penal Code, 1860.
DEPONENT
Verification:
Verified at ____________on this ____ day of ___________ that the contents

of the above affidavit relating to my income and assets are true to my
knowledge, no part of it is false and nothing material has been concealed
therefrom. I further verify that the copies of the documents filed along with
the affidavit are true copies of the originals.
DEPONENT
Digitally Signed
By:RAJENDER SINGH
KARKI
19:33:41

affidavit convict

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ANNEXURE-A

Format of the AFFIDAVIT of the Convict

S. No. Description Particulars

2. Name of Police Station

3. Date, time and place of offence

5. Name of the convict

6. Father’s /Spouse’s name

10. Addresses: Permanent

11. Contact information: Mobile

12. Educational and professional

15. Whether you are assessed to Income

16. Complete details of the immediate

17. If the deponent is a salaried person:

18. If the deponent is self-employed:

19. Income from other sources:

21. Any other income not covered above

22. Total Income Monthly

24. Financial Assets Account Name of Current

25. Investments Particulars Current Value

26. Movable Assets Particulars Cost of acquisition

27. List of other assets not itemized

28. Value of total assets

30. Voter ID Card

31. PAN Card

32. Statement of Account of all bank accounts

33. Income Tax Return(s) of the deponent along

34. Salary Slip in case of salaried persons

Verified at ____________on this ____ day of ___________ that the contents

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Verified at __on this day of _ that the contents