xmlns:atom="http://www.w3.org/2005/Atom" xmlns:atom="http://www.w3.org/2005/Atom"
Election in the................................................................................constituency
[F1 or........................................[F2 district electoral area]],
Date of publication of notice of election................................................................................
The expenses incurred at the above election in support of............................................................, a candidate thereat, by................................................................................
(insert name of person or association or body of persons incurring the expenses) being expenses required by section forty-one of the Electoral Law Act (Northern Ireland), 1962, to be authorised by the election agent, amounted to £ ....................
The written authority of the election agent is annexed hereto.
Signature............................................................Date........................................