FORM 5

(See rule 14 (i))

Nomination Paper

Election to the Grama Panchayat

I nominate Sri / Smt. ………………as a candidate for election to the *………………Grama Panchayat……………..District from the *………………constituency / constituency reserved for Scheduled Cases ** / Scheduled Tribes / Backward classes / Women.

Candidate’s Name	:
His / Her fathers’s / Husband’s name	:
Postal Address	:

His / Her name is entered at Sl. No……………in Part No. …………….of the Electoral Roll for the …………….constituency.

My name is ……………….and it is entered at Sl. No. ………………in part No. …………..of the electoral roll for ……………..constituency.

Date :

Signature of the proposer

* Appropriate particulars of the election to be inserted here.

** Strike off the inappropriate alternative.

(to be filled by the Candidate)

I the above mentioned Candidate assent to this nomination and hereby declare.

(a) that I have a completed……………..years of age

+(b) that I am a woman

+(c) That I am a member of …………….Caste / Tribe / class which is schedule caste / schedule tribe / Backward class of the State of Karnataka. A copy of the Schedule Caste / Schedule Tribe / Backward Class certificate issued in my favour by the competent authority is enclosed.

(d) That the symbols I have chosen in the order of preference:

I

II

III

Date:

Signature of the Candidate

+ Score out the clause if not applicable.

(To be filled by Returning Officer)

Serial number of Nomination paper………….

This nomination was delivered to me at my office at…………….(Hour) on ……………(date) by the candidate * / proposer ………….(Name)

Date:

Returning Officer

Decision of the Returning Officer accepting or rejecting the Nomination paper.

* Score out the word not applicable.

I have examined this nomination paper in accordance with rule ……………..of the Karnataka Panchayat Raj (Conduct of Elections) Rules 1993 and decide as follows.

Date:

Returning Officer

Receipt of nomination paper and notice of scrutiny

(To be handed over to the person presenting the nomination paper)

Serial Number of nominations paper………………

The nomination paper of ………………a candidate for election to the * ……………Grama Panchayat from the * ………………constituency was delivered to me at my office at …………..(Hour)……………(date) by the candidate ** / proposer.

All the nomination papers will be taken up for scrutiny at ……………(Hour) on ……………(date) at ……….(place).

Date:

Returning Officer

* Appropriate particulars of the election to be inserted here.

** Strike off the inappropriate alternative.