| I, Candidate name : |
Md. Samsul Hoque |
| Date of Birth : |
30-11-1981 |
| Father/husband`s name : |
মৃতঃ আহাম্মদ আলী মিয়া |
| Mother`s name : |
মৃতঃ লিলি বেগম |
| Address : |
গ্রামঃ গোপালপুর, ডাকঘরঃ ঝিটকা-১৮৩১, উপজেলাঃ হরিরামপুর, জেলাঃ মানিকগঞ্জ। |
From the constituency of :
Name and number of the constituency |
হরিরামপুর উপজেলা ভাইস চেয়ারম্যান |
Intend to contest in the parliamentary election as a candidate. I am declaring by sworn that,
- 1. My highest educational qualificationএস.এস.সি-and I enclosed herewith a copy of certificate.
-
2. A. I am not accused in the criminal case X Yes : No ? (if applicable put a tick mark)
Or
B. I am accused in the criminal case and details are as follows :
| Sl. |
Laws and sections in which case have been filed |
Name of the court |
Case Number |
Present status of the case |
-
3. A. In the past, no criminal case have been filed against me Yes : No ? (if applicable put a tick mark)
Or
B. Criminal case or cases have been filed against me in the past and the results :
| Sl. |
Laws and sections in which case have been filed |
Name of the court |
Case Number |
Results |
4/ My profession details:-
| Category |
Profession |
| My current profession |
ব্যবসা |
| My previous profession |
|
| Spouse's profession |
|
| Spouse's previous profession |
|
5/ Dependents' profession list :-
| SL |
Name |
Relationship |
Profession |
DOB/Age |
Birth Registration No |
Remarks |
| No dependents information |
6/ Dependent's and my income source/sources :-
| SL |
Source of income |
Candidate's annual income from the source |
Dependent`s income |
| 1 | business | 200000 | 0 |
6/ Myself, person/persons dependent on me and my wife/husband`s assets and liabilities statement
( নগদ টাকা, বৈদেশিক মুদ্রা (মুদ্রার নামসহ), ব্যাংক ও আর্থিক প্রতিষ্ঠানে জমাকৃত অর্থের পরিমাণ,
বন্ড, ঋণপত্র, স্টক একচেঞ্জে তালিকাভুক্ত ও তালিকাভুক্ত নয় এমন কোম্পানীর শেয়ার (পরিমাণ, অর্জনকালীন সময়ের মূল্যসহ)
পোষ্টাল, সেভিংস সার্টিফিকেটসহ বিভিন্ন ধরণের সঞ্চয় পত্রে বা স্থায়ী আমানতে বিনিয়োগ
বাস, ট্রাক, মটর গাড়ী ও মটর সাইকেল ইত্যাদির বিবরণী (পরিমাণ, অর্জনকালীন সময়ের মূল্যসহ)
স্বর্ণ ও অন্যান্য মূল্যবান ধাতু ও পাথর নির্মিত অলংকারাদি (পরিমাণ, অর্জনকালীন সময়ের মূল্যসহ)
ইলেকট্রনিক সামগ্রী (পরিমাণ, অর্জনকালীন সময়ের মূল্যসহ)
আসবাবপত্রের বিবরণী মূল্যসহ অন্যান্য)
(A) Intangible assets
| SL |
Description of assets |
In own name (amount) |
In own name (price) |
In wife/husband`s name (amount) |
In wife/husband`s name (price) |
In dependents name (amount) |
In dependents name (price) |
| 1 | cash_taka | 100000 | |
| 2 | bank_deposit | 5000 | |
| 3 | electronic_goods | 30000 | মোবাইল, ফ্রিজ |
| 4 | furnitures | 50000 | খাট, আলমারী, সুকেজ |
| 5 | others | 30000 | সাংসারিক ব্যবহারিক জিনিষ |
(If the dependents are much more in number, information has to be provided in additional pages)
(B) Tangible assets
| SL |
Description of assets |
In own name (amount) |
In own name (price) |
In wife/husband`s name (amount) |
In wife/husband`s name (price) |
In dependents name (amount) |
In dependents name (price) |
Joint owner (amount) |
Joint owner (price) |
Candidate`s share in case of joint ownerships (amount) |
Candidate`s share in case of joint ownerships (price) |
| 1 | house_apartment | | ১টি টিনসেড বাড়ী |
(If the dependents are much more in number, information has to be provided in additional pages)
(C)(1) Liability Description
| SL |
Category |
Type |
Details |
Amount |
| 1 |
In my name |
|
|
|
| 2 |
In spouse's name |
|
|
|
| 3 |
In children's name |
|
|
|
| 4 |
In dependents' name |
|
|
|
| Total Liability |
|
(C)(2) Government Dues
| SL |
Category |
Type |
Current Status |
Amount |
| 1 |
In my name |
|
|
|
| 2 |
In spouse's name |
|
|
|
| 3 |
In children's name |
|
|
|
| 4 |
In dependents' name |
|
|
|
Or
B. I have elected as member of the national parliament previously.
8/ Loan related information
A. I did not take any loan from the bank or financial institutions
Or
B. I have taken the loan from the bank or financial institutions as follows:
| SL |
Types of loans |
Name of the bank/Financial institutions |
Amount of loan |
Amount of defaulted loan(if any) |
Last date of rescheduling |
| No loan information |
10/ Tax Return Information
| SL |
Category |
Assessment Year |
TIN |
Income Shown |
Asset Shown |
Tax Paid |
| 1 |
Self |
|
|
|
|
|
| 2 |
Spouse |
|
|
|
|
|
| 3 |
Children |
|
|
|
|
|
| 4 |
Dependents |
|
|
|
|
|
I am saying by sworn that all the information provided in the affidavit and enclosed documents are correct and true according to my belief and knowledge.।
Date :
Signature/thumb impression of the nominated candidate
| I do hereby Mr. /Mrs. : |
মোঃ সামসুল হক |
| Date of Birth: |
30-11-1981 |
| Father/husband`s name : |
মৃতঃ আহাম্মদ আলী মিয়া |
| Mother`s Name : |
মৃতঃ লিলি বেগম |
| Address : |
গ্রামঃ গোপালপুর, ডাকঘরঃ ঝিটকা-১৮৩১, উপজেলাঃ হরিরামপুর, জেলাঃ মানিকগঞ্জ। |
| The Mr. / Mrs. (name identifier) : |
জনাব মোঃ আবুল বাসার শুভ |
| Address : |
এ্যাডভোকেট, জজকোর্ট, মানিকগঞ্জ। |
With today being detected
As stated above, upon oath before me on the affidavit has to offer.
Date of information : 2024-04-09
Information sources : According to the Election Commission has prepared this report based on Discounts
