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Affidavit to be Furnished by the candidatealongwith Nomination Paper Before the Returning Officer

F
ri

For erection i::::,%?::ti:3;il:l;;""t

No. Galli, resident House 167, of Aged J. , son .l, At$rasio Monserrate of JoeMonserrate, 49 years, on affirm andstate oathas Election, hereby do solemnly Taleigao, Goa,a candidate theabove at under$ (1)I am a candidate up by Indian National Party, set Congress

r
1

df PAN and status of filinq of Income tax return :

S I .N

Names

Account Permanent (PAN) Number

Totalinco ne yearfor The financial shownln whichthe last Income- Income T tax returnhas been (ir Return filed RuDees)

Monserrate Self- Mr.Atanasio

AEOPM8398H
AFGPM4451G

2010-11

2
3 4 5

JenniferMonserrate Soouse- l\4rs. 1 Deoendent - NA 2 Deoendent - NA 3 Deoendent - NA

2010-11 - NotApplicable - NoiApplicable - NotApplicable

.00 512,50 r.00 116,00

has beentaken by (3) The followingcase(s)is/arependingagainstme in which cognizance court:-

and 47 The detailsof caseswherethe coun 143.1 i 4AJ 49.153,324,325,326,332,333'427 Act to nd Sec. 3 of the Prevention PublicProperty of Sections hastakencognizance. of Act and Description the offence It is alleged that the accused led a morcha to Panali stationon accountof the failureon the part of the police taken whichcognizance lt elements. ls to inspector arrestcertainanti-social led by Ata.nasioMonserrate alleged that the crowd , station the and violenvunlawful attacked police 34 , v u/s r . , , w u l o . 92/10/C J t v t f I at r r d l t ll. Caselno. J z t t v t v -- JMFCa t . dPanaji r . !353 r/w v a ,IPC fl. uasc aftercomi[lg others amongst thatthe deponent It is alleged know about the afrest of his wife forcibly tried to entef t

1 7 c c N o . 9 2 / 1 0 /-c 4 . 0 2 0 1 0
No. Petition 8'1/2010. 1& Criminal 2/201 No. Petilion (s) (s) of Details Appeal i Application the 1 No. Criminal 421201filedbefore (if any)filedagainsi the Writ Petition for revision Goa. at of Bombay Panaji, HighCourt

to by in 4. Cases which I havebeenconvicted a court qf !!q otherthosereferred in Form26):


The detailsof cases,sectionsot the of Acl and description the offencefor : { a ) whichconvicted CaseNo.and Nameof the Courl(s), ( b ) Date(s) orde(s): of : imposed c ) Punishment

-------NrL------

etc') of myself, (5)That lgive hereinbelow the detailsofthe assets(movableand immovable my sPouseand all dePendents: A. Detailsof movableassets : (Note: will of l indicating extent ownership alsohaveto be glven the l Assets iointname in the Amount, Daieof Deposit, scheme, Numbef, 2Incaseofdeposiulnvestment,thedetailsincludingserial are and Nameof Bank/lnstitution Branch to be given in valuein stockExchange respectofllisted market as per 3. Valueof Bonds/share/Debentures the current be should gaven. companies and companies as per booksin caseof non-listed of dependent the income the candidate' on substantially a heremeans person, 4. Deoendenf. givensepefately respect eachinvestment) in of is including amount to be 5. Details

Sr
No r)
(ii)

Degcription
Cash in Hand

Self

INR

2 472.857 tNR

Spouse 2.472,451

Depsnddnt 1 l

Dependent 3 - NotApplicable Dependent

(FDRs, and TermDeposits allother including Saving typesof Deposits withFinancial Deposits accounts), Financial Non lnstitutions, Banking and Companies Cooperative and the amountin each societies suchdeposit
(iii)

tNR

6 4 5 29 9 3 t N R

6.452,993

- Not Applicable-

(As oer Annexure l) tNR

l) {Asoer Annexure 3.240.349 - NotApplicable

in of Details investment Bonds, and Debentures/shares unltsln Fuodsand otheF companies/Mutual andthe amount

rNR 3,240.349

ll) {As DerAnnexure

ll) fAs oerAnnexure

Details investment NSS,postal of in policies Savings, lnsurance and investment any Financial in nstfument Post office or in Company the amount and rNR Personal loans/advance givento any or entity including firm, , Tfustetc and other receivables from debtorsand the amount. rNR MotorVehicles/Aircrafts achts/Ships (details lvlake, of Registration etc,Yearof No. Purchase amount) and
(vii) Jewellery, bullion and valuable thjng

2,875,263 rNR

2,875,263

16,647,743 INR

16,647,743

rNR

'11,796,891 INR

11 , 7 9 6 , 8 9 1

(9ivedetails weight of and value)

otherassets suchas valueoF


viii)

1765.5 gram= Per 1765.5 gram= Per tNR 2,634.956 INR .1,089,973

tNR

_ 1,089,973

(Asper Annexure Vl) (AsperAnnexure Vl) l NR 4 7. 2 1 1 l NR 4 7. 2 1 1

( N o t e r1 Properlies jointownership in indicating extent jointownership alsohaveto be indicated the of will 2 . Eachlandor buiiding apartment or should mentioned be seperately thisiormat.) in

INR

2]77sA0 INR

2,177,600

rNR

5,022,500
IN R 9.7

7,{' sq.ft.)

Built Area(Total up measurement In

- Vll As DerAnnexure Vll AsperAnnexure


No
NO

Whetherinheritedprooertv (Yesor uate ot purchaseIncaseot sell acouiredorooertv Costof Land(incase purchase) of at the time of purchase Any Investment the land by way ol on develooment, construction etc.

- NotAoglicable - NotApplicable - NotADD|icable , - NotAoolrcable '

- Vll As oer Annexure Vll As perAnnexure INR tNR INR 8,974.058 t N R 8,974,058 38,128,750

Current market value ooroximate

rNR

3 8 , 1 2 8 . 7 5t0 R N
INR 68.'t81.850 NR I

- NotADDlicable - NotAoolicable - Not Ao0licable-

(vi)

Others(such interest prooedv) INR as in lotal of uurrent Marl(et value ot (l to (v) above INR

68.18'1.850

- Not Applicable-

(5) | give hereinbelow the detailsof liabilities/ dues to publicfinancialinstitutionsand government (Not6:Pleasegive separatedetailsof nameof Bank,institution, :entityor individUal and amountfor each item D e p e n d e n t | D e p e n d e n tI- D e p e n d e n t S . N ( Description Self Spouse I 3 Loan or dues to Bank/Financial (i) - NotApolicable Institution(s) tNR 2.636,430 INR 2,636.430 Nameof Bank Amount outstanding Nature loan of Loanor dues to anv individuals/ Entitvother than mentionedin (i) above. Name(s) Amount outstanding Amount outstanding Nature loan of As perAnnexure Vlll As pef Annexure Vlll As per Annexure Vlll As per Annexure Vlll As per Annexure Vlll As per Annexure Vlll - NotAoolicable - NotApplicable - NotApplicable

rNR 3 3 , 9 2 2 , 7 6INR 9 33,922,769 As perAnnexurelX As perAnnexure lX As perAnnexurelX As perAnnexure lX As perAnnexurelX As perAnnexure lX - lX As perAnnexufe lX AsperAnnexure rNR 692,351 NR 692,351 - lX As per Annexure- lX As perAnnexure t N R 3 7 , 2 5 ' 1 . 5 5 0 .INR 37.251.550.00 00
NIL

- NotAoplicable - NotAoolicable - NotApplicable - NotADDIicable - NotAoDlicable - NotApplicable -

Grandtotal of liabilities (ii)

Government Dues: Dues departments io dealing with government accomodation


Duesto departments dealing with suPPly water of Duesto departments dealing with supplyof electricity Duesto departments dealing with supply telephones/mobiles of Duesto departments dealingwith government (,ncluding transport arrcrafts and helicopters) Income Tax Dues WealthTax Dues ServiceTax Dues Munrcrpal/Prope(V Dues Tax Sales Tax Dues ,nyotherdues Grandtotal of all Govt,dues Detailsof profession occupation: or a. Self- Business b. Spouse Business

NIL NIL NIL NIL

- NotAoolicable - Not Applicable - Not Applicable-

NIL NIL NIL

- NotApplicable -

NIL 4,823.00 NIL NIL NIL NIL NIL 2.994,823.00

NIL 41.607.00 NIL NIL NIL NIL NIL 3,641.607 00

- NotApplicable - Not ApDlicable -

- NotAoolicable - NotAoolicable - NotApplicable - NotApplicable - NotAoolicable - NotApplicable -

(8) My educational qualification as unoer: is Shri Atanasio Monserrate SeniorSecondary Examination( council ofSecondaryEducationMohali)intheyear2009 (Givedetails highest of School University / education fullformof the certificate/ with diptoma/ degree course) (Name ihe School of /College/ University the yearin whichthe course and was comoleted.) ABSTRACT THE DETAI. S G I V E N N ( 1 )T O ( 8 )A B O V E : OF I 1
Name of the candidate

2 Fullpostaladdress
Numbef and Name constrtuency and state of th

Shri.lsrauKurF. AtanasioMonserrate '167, Galh. Taleiqao, Goe l!9!s9 No

F r o m 1 - S t .C r u z G o a . 3 ,

Nameot the Polltical partywhich set up the candidate (otherwise write 'lndependent')

INDIAN NATIONAL CONGRESS

N a m eo f t h e b a n k
Corporation Bank-Tonca A x i s B a n kL t d . 4 l 8 5 4 ( Bankoflndia 15921 Jennifer ) Bankof India( Atanasio A/c 9870 ) ifef Canara Bank23169( Jenn ) C o r p o r a t i o n n kl l 7 l 7 ( J e n n i f e)r Ba Bank 1323 Corporation Corporation Bank I458 Corporation Bank 1558 Bank 1586 Corparation Corporation Bank9699 Bank SB/01/00q407 Corporatior'r Corporation Bank Toncali00 D e n a a n k6 1 0 3 B ( Jennifer HDFC00591000046740 ) HDFCBank76528 HDFCBank 372 I C I C IB a n kI 1 7 0 8 l c l c l B a n k0 0 1 5 0 1 0 1 9 0 I f l D B l B a n k i i 2 l 4( J e n n i f e) 2 ( KotakBank20000304 Atanasio ) KotakMahindra No. 1000!103 A/c Mapusa UrbanBank CD/ 25803 Mapusa UrbanBank SB/ I i754. OBC/CTB

A/c Tvpe
FixedDeposit Savings Sav ings Savings Savings Savings A/c Current Savings Savings Savings Savings Savings Savings Savings Savings Savings Savings Sav ings Savings Savirrgs Savings Savings Current A/c Savings Savings Savings Savings Savings Savings Savings Savings Savings CurrertA/c Current A/c

(in Amount Rs.)


| ,37| ,467 .44' 39,643.00, 20,76'7.00 r,278,s84.10 't ,684.15 't 6,97 6.00 5,43 4,130 .42 24,494.00 . 17.00 257.89 r5,962.00 65i.984.00 t5,402.00 21,829.01 78,220.08 5t,322.59 r0,356.94 r0,000.00 I 6 , 6 0. 0 0 t 795,68.i2 | 4,332.34 28,902.08 8,988.00 25,551.05 t 7 5|.8 74 . 1 7 74 . 1 7 83,684.9 | 6 s1 7 1 4 . 3 1 , 2.48't .69 8,490.60 60,070.00 1,058,457.-57 1.045.065.86 12,905,985.13 6,452,993.00 6,452,993.00

oBc/cTB r69 r3
OBC/GTBA/c No. l3 170 ( S B I I 1 0 3 5 8 8 i 6 8 J e n n i f e)f 1 S B IA / cN o . I 1 0 3 1 6 0 2 1 7 9 Syndicate BankA/c 13893 Uco Bank2578 UTIBarrk /cNo.39224 A Coryoration Bank 1595 I C I C IB a n kI 4 9 3

Total
50% share under communionof assets Shri.Atanasiol\4onserrate

Smt. Jennifer Monserrate

A N N E X U RIE I Investment Shares& Mutualfunds as at 31/03/2011 in N a m eo f t h e f u n d / C o m p a n y a) Mutual Fund KotakMahindra Mutual Fund DSPMerryl LynchlMututal Fund a) Shares ln RajHospitality Ltd. Pvt. (1997Shares Rs.304492 per share) at Total 50%shareundercommunion assets of Shri.Atanasio Monserrate Smt.Jennifer lvlonserrate C o s t( i n R s . ) 200,000 00 200,000.00 6,080,698.71 6.480.698.71

3,240,349.00 3,240,349.00

eatoup viildaEin
LICPoticy 930912470 No. LICPolicy 930755903 No. Torat(a) provident Public Fund Total(b) GrandTotat(a+b)

1,250,000.00 1,500,000.00

Valueas on 3113t2011

5mt.Jennifer Monserrate

2,875,263.0O 2,875.263.OO

ANNEXURE IV

n"" ?ers9!.ellq3rs&dv.
Namesof the panies eduance To*ardspiilrasibi proiiE Advance purchase Flar for of

AmountRiiEin
3113t2011 2,400,000.00 | ,47 9,479 .OO 666,666.00 666.666.00 666.666.00 r.i0.000.00 t50,000.00 250,000.00 t09,500.00 800,000.00 250,000.00 t00,000.00 I 5t , 6 6 6 . 0 0 250,000.00 436,000.00 849.000.00 r00,000.00 230,678.00 9.000.000.00 500,000.00 500,000.00 600,000.00 l]8,012.00 r,400,000.00 500.000.00 8.-r21.668.00 2,t7t,900.91 78,445.00 40,003.00 t0,000.00 56,500.00 261.400.00

ClaraPholomena Dias MariaRitaDias RitaAntonefta Dias VelhoConstruction Verner Velho palyekar Devidas EdwinMascarenhas CroupCorstruction Curudas Mayekar lnacioPereira .iayesh Micheal Viegas Rui Pinto Verner Zacquaris Monteiro Sharayu Automobiles Advalpalkar Constructions Caetano Souza D Digirech FlorieViegas Cood EarthDevelopers MudhirCupra Udayl\4adkaikar Raj Hospiraliry Ltd pvt RohitMonserrate Priority Automobiles Kala Moters RentReceivable TDS Receivable(Ninad Laud) TDS Receivabte(Edith de) Kotal Securities

3J.295,485.96

16,641.74?.c)8 t6,647,712.98

Four Wheelers Toyotaprado Mercedes BenzC 230 Mercedes BenzE CDI 350 ruercedes BenzG 655AMG l a t aX e n o n Maruti Omni Maruti Omni fMaruti Omni Maruti Omni Hyundai ii0 SkodaSuperb ToyotaFortuner Toyota Captiva Two Wheeters RoyalEnfield et Bu Kinetic Honda Kinetic Honda TVS Scooty TVS Scooty Kinetic Honda Kinetic Honda KineticHonda Kinetic Honda Kinetic Honda Kineiic Honda Kinetic Honda TVS Scooty Kinetic Honda ryS Scooty Honda Dio Kinetic Honda Kinetic Honda

cA_08-F_0001 cA_o7_E_010.1 GA_07_L-0026 cA_07_L_OOO1 cA_07-c_7178 cA-07_E_3129 cA-07-C_6932 cA_07-c_6933 cA_07_C_6934 cA_07-E_0380 cA-07_L_0333 cA-09_E_0333 cA_09_D_0s33

12t09t2006 26/05/2009 27t06/2011

04t07t200s 20t07t2010

24/01t2011 29t12/2009 Q1/07/2009

cA-07-H-3162 GA-01_H-2500 GA-01_H-7376 cA-01-Y-2753 cA-07-B-2995 cA-?1_Y_1249 GA-01_Y_6330 cA-01_Y_0650 GA-01-Y_6221 GA-o1-Y_6218 GA-01_Y_0674 cA-01-H-6560 GA-07-8_2627 GA-01-Y-6247 GA-07-H_8708 GA-07_J_3634 GA-01-Y_6247 GA-01-Y-2862

25/07t2ao5 13/'10t1999 01t06/2001 12/08t1999 11t05t2001 14t05t2001 16/08/1999 06/04/1998 24t03/2005 16t05t2001

Total Value

ffi
ANNEXURE VI Business Assets(Hear ine) uusrness Assets(Raj Constructions) Total

23,593,781.00 11, 7 9 6 , 8 9 1 . 0 0 11 , 7 9 6 , 8 90 0 .1

varueas on 311312011 642,580.00 438,165.00 '1,099,200.00

5mt. Jennrfer Monserrate

::rT"';.c:':d;::"*llry

z,tzg.gqsno
1,089,973.00 1,089,973.00

andDetails lmmovable p of Field, Corlim Tiswadi-Goa

Builtup Area(Total measurement in

Current Market Value Rs.

36/55)

Dhavem Field, Corlim Tiswadi_Goa (surveyNo 35/40) Dhavem Field, Corlim Tiswadi_Goa (surveyNo 37120) Dhavem Field, Corlim Tiswadi-Goa (survey 3S/23) No Dhavem Field, Corlim Tiswadi_Goa (surveyNo 34/30) Dhavem Fteld, Corlim Tiswadi_coa (surveyNo 34/SO) Dhavem Field, Corlim Tiswadi_Goa (surveyNo 36/53)

412,500.00

100,000.00 275,000.00 700,000.00 725,000.00 587,500.00 600,000.00

1
Property nearchurch at (Survey No. 17011) property Taleigao at (Survey 167/7) No.

065.d1

182.00

18/09/1985 'i8lp9/1995

432,000.00l

336,000.00

'o:1 schoot (reased) No raleis ::::^1 at Tateigao(Survey (ptot 6&10), Hroperty No. i6715) (attached t"o Casa Monserrate)

5,858,200.00 1,820,000.00

1 , 5 4 0 . 0 0 12tO3/2010 1,414.00

3,203,200.00 1 5 , 4 0 0 , 0 0 0 . 0 0 384,000.00 1 4 , 1 4 0 , 0 0 0 . 0 0
37,218,20Q.0Q

30t07t1997 2

KamatMansion ShopNo 1, 2. 3, 4 Mnamar KamatMansjon ShopNo.5,Miramar KamatMansjon ShopNo.7, Miramar at Pooja npts.,Opp.KamatMansion, Tonca llop Snopat KamatClassic. Tonca No.FF3 VelhoTradeCentre, at panajj :hop KamatMansion, Shop. No.6,Miramar KamatMansion Shoppremises (No g), Miramar KamatMansion Shoppremises (No g), Miramar K a m a M a n s i o S h o pN o .1 0 ,M i r a r n a r t n

flf;: "t

nirui Sadan (office 201202,302, No. . 103),

2st11/1999 Q4/10/1999 12t07t2000 13t07t1992 21t04t1999 02103/1999 09/06/2000 18/09/1995 06/08/1999 04t10t1999 21t04t1995, 19/06/1995, 28/0711997. 1 1 2 . 2 0 23106/1990
't

4,000,000.00 1,000,000.00 900,000.00 300,000.00 500,000.00 250,000.00 900,000.00 100,000.00 495,000.00 600,000.00

5,760,000.00 1,440,000.00 1,440,000.00 1, 1 8 4 , 0 0 0 . 0 0 1, 1 8 0 , 0 0 0 . 0 0 480,000.00 1,440,000.00 1.440,000.00 1,440,000.00 1,440,000.00

1,000,000.00 2,244 .00 ,000 10,045,000.00

Houseat Taljegao (Survey No. 167/6) Bungalow Tateigao at (Survey 169/3) No. SmallHouseat Taleigao (Survey No. 167i2) House Cazacho at Accor,Taleigao (Survey No. .Umatt 186t2) KamatMansion No.2 Flat KamatMansion No.3 Flat Kamatl\/ansion No.4 Flat KamatMansion No.5 Flat Flatat CruzApts,La Campala, Miramar FlatNo 5-5(26), KamatClassic, at Tonca flat No.501,5th Floor, park,St.paulRoad, Central Bandra (W) FlatNo.307,Rahe.ia Residency, Bangatore

165.00 2 8 t 1 1 t 1 9 8 7| 240.00 213.00 30t07t1997 I 474.00 't12.00 Dec-98 I Dec-98 I

1 , O O O , O O 0 . o 0 5,775,000.00

8,400,000.00
1,OOO,OOO.OO7,455,000.00

300,000.00 16,590,000.00 800,000.00 3,920,000.00 94.00 2000 | 70o,ooo.oo 3,290,000.00 107 .00 23tO9t2O00 900,000.00 3,745,000.00 I 108.00 16t05t2000 900,000.00 3,780.000.00 I 140.00 20/01t1986 | 280,000. o0 4,900,000.00 126.00 2 1 t 0 4 / 1 9 9 9I 1 , 0 0 0 , 0 0 0 . 0 0 4,410,000.00 83.33 22/12t2009 10,000,000.00 10,000,000.00 | 159.70 1 9 / 0 4 / 1 9 9 3 1 . 0 6 8 ,1 6 . 0 0 1 I 3,992,500.00
1 7 , 9 4 8 11 . 0 0 ,6 32,348.316.00 136,363,700.00

o t a l( 1+ 2 + 3

Smt.

S h r i .Atanasio Monserrate

507"share unoeiio mEIn=E niia-G6i!-

68,181,850.00 68,181,850 0

Nameof Institution

IndBank Ltd. -lrs IndBank Ltd. IFIDUS


Ltd. tF lt\Lru5 lnd tsank I N D U St n dB a n kL t d . I n d u s n dB a n kL t d I Corporation Bank

Natureof Loan Loan lHousing lCar Loan t^ Loan luar Car Loan Car Loan Car Loan Dr. Bal in Savings Nc

Amount O/S
3,s71,928.00 421,334.12 49.812.18 73 , 8 7 . 0 7 4 48,304.29 1,107,544.54 62.-1 I

5,272 .39 ,859 Shri.Atanasto Monserrale Smt.Jennifer Monserrate ANNEXURE IX Loanor dlrect 2,636,430.00
2.636 430 00

Mmes of the parties


pvt Raj Hospiraliriy Ltd TarvelAdvance from Raj Hospitality Ltd pvt Deposit Towards Rent AlshaConstruction AnthonyMendes ChaseRealEslateDevelopeers Landscape Developers Samriz Construction Tanvirnan Man powerService Advance TwdsSale KamatMansion of Shop I .2,3,4 Advance TwdsSale Karnat of Mansion Flats( Flat 4 N o .5 , 6 , F - 5 ,S -t ) AnandBose Ashray Construction B a n j uP a d i l l Essal Builders Cracious J o h nP a u l MarioFernandes N icoias Fernandes Pravin EarthMovers Rachila CLrpta velho e. R u iP i n t o SadikNoorani S a d i q uS h a i k h e Sira.1 Shaikh V e n r e A l e x i oV e l l r o r Pasa Properties Landscape Developers Totat

on 31t3t2011
3,803,893.60 9.t24,967.00 I , r 7 5t,7 8 . 0 0 700,000.0b s00.000.00 600,000.00 r.s00,000.00 r.000,000.00 r,700,000.00 3,I50.000.00 2.s00,000.00 r6,000,000.00 r,000,000.00 2,r60,000.00 169,000.00 s00.000.00 500.000.00 t-50.000.00 1s0,000.00 700.000.00 900,000.00 2.50.000.00 800,000.00 600,000.00 r0,050,000.00. 985.000.00 3,307,500.00 3,620.000.00 250,000.00

@s Atanasio bnrr.

Monserrate

Smt.Jennifer Monserrate
Sundry Creditors Provisions Total

33.922.7 69.00 33,9?2.769.00

718,546.09

606. r5s.00

sf of 197: areunlelrgnrnu!.lan assers Shri. Atanasio Monserrate


Smt.Jennifer Monserrate

fir

VERIFICATION l, Atanasio Monserrate, Deponent, J. the abovenamed, herebv do verifvand declare thatthe contents this of affidavit the contents the annexures and of enclosed herewith trueand correct the bestof myknowledge are to and belief, partof it is falseand nothing no material beenconcealed has therefrom.I further declare that :' (a) Do nothaveanyotherconviction pending or casesagainst otherthanthosernentioned items3 and 4 me in above: (b) I, my spouse, my dependents not haveanyassetor liability, or do otherthanthosementioned items5 and 6 in above.

Veriried...PS.n4.al/.=.AA...the...1144....... at rhis . ...aav or

Solemily aftirmsd 8nc xecuted bcfore me

;; Jsso,ot"!1sYqexoK'

l] (AIIll'ANAi'n Prlti5lilKtRr
NNT^F'Y Ntiilii nil,\ srArE ci. G- A ,(iNOtA)

A:I"ll?--...-rce.uo.5.36.1

\ d r \ o\r \ a l a o l ) _

.j,,-=Il#

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