Forms under Orissa Panchayat Samiti Election Rules,1991
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(See Rule 8)
Notice calling for nomination of candidate for the office of Member of Samiti of ………………………………..Samiti Constituency of …………………………………….Panchayat Samiti.
Notice is hereby given that
(1)An election is to be held for the office of every Members of Samiti of……………………..Panchayat samiti.
(2)Forms of nomination papers may be obtained at the office of the Officer specified in Serial No.6 between the hours of …………………………and …………………………..on ……………………… (Date) at (Place)…………………………
(3)Nomination papers may be delivered between the hours of 11 in the morning and 3 in the afternoon by a candidate or his proposer to the Officer specified below, at his office on any date not later than the …………………………..day of …………………………
(4)The nomination papers will be taken up for scrutiny at …………………………………………hours on……………(Date) at………………………………….(Place).
(5)Notice of withdrawal of candidature may be delivered by a candidate, to the officer specified below a this office before………………………on……………………..
TABLE
Designation of Officer Location of office
(6)Election Officer
……………………………..
(7)In the event of the election being contested, the polling will take place on………………………………between the hours of…………………………
Date …………………..
Place……………………
Election Officer,……………..Samiti
(See Rule 8)
Statement showing the Samiti Constituencies for which election is to be held
No. of samiti Constituencies
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Name of the Samiti constituency
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Name of the Grama Sasan constituting the Samiti Constituency indicating extent of such Constituency |
If Reserved, status of reservation |
(1) |
(2) |
(3) |
(4) |
Election Officer
[See Rule 11(3)]
Receipt of deposit amount
| No......................dated................. Received from Shri.......................... Rs.........................Rs.(..........................................................) On account of security deposits for candidature for the office of the member of Samiti of Panchayat Samiti.............................. Place...............
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No......................dated................. Received from Shri.......................... Rs.........................Rs.(..........................................................) On account of security deposits for candidature for the office of the member of Samiti of Panchayat Samiti.............................. Place...............
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[See Rule 27 (5)]
Receipt for deposit of objection fee
No………………………… Dated………….
Received from Shri/Shrimati…………………………………………….
Rs……………………….(Rupees……………………………………………) on account of objection free being forfeited during election to …………………………Samiti Constituency.
Polling Station………………………
Presiding Officer
[See Rule 11 (10)]
NOMINATION PAPER FOR MEMBER OF SAMITI
(1)Name of the Samiti Constituency for which
the candidate is nominated.
(2)Whether nominated for reserved seat, if so details thereof.
(3)Full name of the candidate
(4)Serial number of candidate in Electoral Roll
with Part No.
(5)Father's or husband's name
(6)Age
(7)Address
(8)Community
(9)Full name of proposer
(10)Serial number of the proposer on the Electoral Roll
with Part No.
(11)Signature of the Proposer
(12)Full name of the Seconder
(13)Serial number of the Seconder in the Electoral Roll
with Ward No.
(14)Signature of the Seconder
CANDIDATES DECLARATION
I declare that I am willing to stand for election to the Office of the Member of Samiti of……………………………………Panchayat Samiti.
Signature of candidate
Endorsement by the Election Officer Serial Number……………………..
The nomination paper was presented to me by …………………………. at ………………………………on ……………………….
Decision after scrutiny Signature of the Election Officer
[See Rule 11 (12)]
Declaration of result of uncontested candidate
I do hereby declare that Shri/Shrimati……………………….has been elected uncontested as the Member of Samiti for …………………….Samiti Constituency of ………………………………….Panchayat Samiti.
Election Officer
[ See Rule 11 (13) & (16) ]
List of validly nominated / Final list of candidates for election as the Member of Samiti for …………………. Samiti Constituency. Panchayat Samiti……………………………………
Serial No. (1) |
Name and description of candidate (2) |
Address of candidate (3) |
REMARKS (4) |
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. |
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Date …………
Place……………………
Election Officer
N.B. – Strike out whichever is not applicable
[ See Rule 11 (13)]
Statement showing the election Symbols allotted to the candidates for the election of the Member of Samiti of ……………………….Panchayat Samiti.
Serial No. (1) |
Name of the candidate (2) |
Symbols allotted (3) |
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Election Officer
[See Rule 11(15)]
Notice of withdrawal
Election to the …………………………………………………………………………….
To
The Election Officer,
I……………………………………………………………………a candidate nominated at the above election do hereby give notice that I withdraw my candidature.
Place ………………………
Date………………………..
Signature of the Candidate
- This notice was delivered to me at my office at …………………………(hours) on……………………………..(date) by……………..……………..………………(name)
- Date ………………………..
Election Officer
Receipt of notice of withdrawal to be handed over to the person delivering the notice.
The notice of withdrawal of candidature by a candidate at the election to the …………………………….was delivered to me at my office ………………….. at ………………………………(hours) on …………………………(date)………………
Election Officer
[See Rule 15 (1)]
Ballot Paper
Name of
Number Samiti Constituency
…………………………………..…….. Panchayat Samiti Election , 20……………..
Election Symbol
(1) |
Signature with seal of the
Presiding Officer Voter’s stamp of marking (2) |
[See Rule 19 (V)]
Ballot Paper Account
Election to the office of the Member of Samiti of …………………………………… Samiti Constituency of …………………………….. Panchayat samiti…………………………
Total number |
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1. Ballot Paper received |
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| 2. Ballot Papers not used | |
| 3. Ballot Papers issued to the voters | |
| 4. Ballot Paper cancelled | |
Name of polling stating ……………………………………………………..
Date …………………………….
Signature of Presiding Officer
[See Rules 19(2) and 31 ]
Result after counting of votes for election to the Office of the Member of Samiti
Name of Samiti Constituency……………………………………
Name of the Panchayat Samiti…………………………………..
Sl. No. (1) |
Name of the Candidate (2) |
Total number of valid votes cast in the polling stations (3) |
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. |
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Total number of ballot papers rejected ……………………………………..
Total number of ballot papers found
in the ballot boxes of polling stations………………………………………..
Date………………….
Place…………………
Signature of the Presiding /Election Officer
[See Rule 32(3)]
Result of counting of votes for election to the Office of the Member of Samiti
Name of Panchayat samiti…………………………..
Name of Samiti Constituency……………………….
Serial No. (1) |
Name of the candidate
(2) |
Total numbr of valid votes cast in all the polling stations (3) |
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. |
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Total number of ballot papers rejected……………………………………………
Total number of ballot papers found in the ballot boxes…………………….
Shri/Smt…………………………………….son/daughter/wife of ……………….
is declared to have been duly elected as the Member of Samiti from ………………………………Samiti Constituency.
Date ………….
Place ………..
Election Officer
N.B. – Separate from shall be used for every Samiti Constituenc
[See Rule 38(1) (i)]
NOTICE
Notice is hereby given that the first meeting of the ……………………….
Panchayat Samiti shall be held at the place mentioned below on ……………..
(date) at ……………………….(time)
Place of meeting …………………………………………………………………………..
Election Officer
[See Rule 38 (I) (ii)]
Notice calling for nomination of candidates for the Office of the Chairman and Vice-Chairman of ……………………..Panchayat samiti.
Notice is hereby given that-
(1)an election is to be held for the Office of the Chairman and Vice-Chairman of………………………..Panchayat samiti.
(2)Forms of nomination papers may be obtained at the Office of the officer specified in serial No.6 between the hours of ………………………and ……. On ………………..(date) at ………………………………(place).
(3)Nomination papers may be delivered between the hours of 11 in the morning and 3 in the afternoon by a candidate or his proposer to the office specified below, at his office on any date not later than the ……….. day of ……………………………………
(4)The nomination papers will be taken up for scrutiny at …………………… ……………………………….hours on ………………………………….(date) at ………………………………..(place).
(5)Notice of withdrawal of candidature may be delivered by a candidate to the officer specified below at his office before closure of office hours on the date of scrutiny.
TABLE
Designation of Officer Location of Office
…………………………………. …………………………………………………………
(6)Election Officer
……………………………………………..
(7)In the event of the election being contested, the poll will take place on ………………………….between the hours of ………………………………….
Date …………………
Place ………………….
Election Officer
………………..Samiti
[See Rules 39 ]
Nomination paper for election of Chairman and Vice-Chairman of ……………..Panchayat Samiti
We (name) (1) Proposer…………………………………..
(2)Seconder………………………………….
Members of Samiti do hereby nominate Shri …………………………son of /Wife of Shri …………………………………….of village ………………………….. Post Office district ……………………………. and who is a member of …………………………..Samiti from………………………. Samiti Constituency as a candidate for election as Chairman / Vice-Chairperson ……………………………Panchayat samiti.
Signature of Seconder Signature of Proposer
Date ……………………. Date …………………..
I , the undersigned …………………………..a person duly qualified for election as above ……………………….hereby record my willingness for being nominated.
Signature of the Candidate
Date ……………………..
ENDORSEMENT BY THE ELECTION OFFICER
Serial No………………
This nomination paper was presented to me by …………………………..
(name) ………………………………………………….(date and hour)
Date …………………….
Place ……………………
Signature of the Election Officer
ORDERS OF THE ELECTION OFFICER
Accepted / rejected ……………………………
Reasons for rejection ………………..
Date
Place
Signature of the Election Officer
[See Rule 42]
Result of counting of vote for election to the Office of Chairman/Vice-Chairman, Panchayat Samiti
Name of Panchayat Samiti ………………………………………………
Serial No. (1) |
Name of the candidate (2) |
Total number of valid votes cast (3) |
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. |
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Total number of ballot papers rejected ………………………………………
Total number of ballot papers found in the ballot box [ ]……………………….
Shri ………………………………………..son of …………………………..a Member of Samiti for …………………………………Samiti Constituency is declared to have been duly elected as the Chairman/Vice-Chairman of …………………………Panchayat Samiti.
Date…………………………
Place …………….
Signature of Election Officer
Note – (i) Separate form shall be used for the election of Chairman and Vice-Chairman.
(ii)*Strike out which is not applicable.
(See Rule 7-B, 7-D, and 8-F)
(List/Statement of Constituencies)
Name of the Block: Total number of Constituencies
Men Women
Constituencies reserved for
S.C.
S.T.
B.C.
U.R
Sl. No.
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Name of the Constituency
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Extent of the Constituency
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Population
S.C. S.T.OtherTotal
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Percentage to the total population of Constituency
S.C. S.T
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If reserved for which category
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(1)
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(2) | (3) | (4) (5) (6) (7) | (8) (9) | (10) |
COLLECTOR
(See rule 7-B)
NOTICE
Notice is hereby given that a statement showing the number of Constituencies, extent of each Constituency and status of such Constituency for such reservation has been prepared in accordance with the provisions of the Orissa Panchayat Samiti Act, 1959 and copy thereof is available for inspection at ………………………………..
Objections or suggestions in this regard may be filed in the office of the undersigned or may be sent by post so as to reach him not later than ________________________________
Collector
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