FORM FC-4





INTIMATION TO THE CENTRAL GOVERNMENT OF RECEIPT OF FOREIGN CONTRIBUTION RECEIVED BY A CANDIDATE FOR ELECTION



[See rule 4(b)] [Section 6(2) of the Foreign Contribution (Regulation) Act, 1976]



1. Name in full (in block letters)

2. Date of birth

3. Name of father

4. Present address

5. Permanent address

6. Date on which duly nominated as a candidate for election to a Legislature and particulars of Legislature [see sections 2(l)(b) and 2(l)(f) of the Act]

7. Full particulars of foreign contribution received within 180 days immediately preceding the date on which duly nominated as a candidate for election to the Legislature

8. Nature and full details of the contribution including value

9. The mode/channel of receipt

10. Purpose for which contribution was received

11. Particulars of the foreign source from which contribution received:

(a) If an individual, his personal particulars including name, (a) present address, permanent address, nationality, profession

(b) If an organisation/institution/association/trust/foundation/ (b) trade union, etc., full, particulars thereof including:—

(i) Full name and complete address (i)

(ii) Address of head off ice /principal office (ii)

(iii) Aims and objects (iii)

(iv) Particulars of important office bearers (iv)

12. Nature of connection /dealings with the foreign sources

13. Details of actual utilisation of the contribution:

(a) Specific purposes for which utilised (a)

(b) Full description of the manner in which utilised (b)

14. Any other information of significance which the applicant may like to furnish

DECLARATION



I hereby declare that the above particulars furnished by me are true and correct.

Place....... ..............

Date .............

Signature of the candidate

Certified that the above declaration was signed by Shri ............................... S/o ............... resident of ..................... a candidate for election to ()1 .............. before me on this................ day of 19 ...............

Signature2

Name in block letters

Designation

[To be signed by a Class I Gazetted Officer3 or a 1st Class Magistrate]

1. Here specify the "Legislature" as defined in s. 2(l)(f) of the Act.

2. Of the State or Central Government.

3. Of the State Central Government.