I, A.B., of , having been requested to assist C.D. (in the case of a blind person voting as proxy add “voting as proxy for M.N.") who is numbered on the register of local government electors for the . . . F1 [[F2[division of the county/county borough of]] ] to record his vote at the poll now being held under the M1Licensing Act 1964 in the [F2said [county/county borough]], do hereby declare that [I am entitled to vote as an elector at this poll] [I am the (state relationship) of the said voter and have attained the age of [F3eighteen]], and that I have not previously assisted any blind person [except E.F., of ], to vote at this poll.
Textual Amendments
F1Words repealed by Local Government Act 1972 (c. 70, SIF 81:1), Sch. 30
F2Words in Sch. 8 Appendix, Form D substituted (1.4.1996) by 1994 c. 19, s. 66(6), Sch. 16 para. 22(10)(d)(with ss. 54(5)(7), 55(5)); S.I. 1996/396, art. 4, Sch. 2
F3Words inserted by Representation of the People Act 1969 (c. 15), s. 24(2) and saved by Representation of the People Act 1983 (c. 2, SIF 42), Sch. 7 para. 4
Marginal Citations
(Signed), A.B.
day of , 19 .
I, the undersigned, being the presiding officer for the polling station for the . . . F1[F2[division of the county/county borough of]] ], do hereby certify that the above declaration, having been first read to the above named declarant, was signed by the declarant in my presence.
(Signed), G.H.
day of , 19 .
at minutes past o’clock.
[a.m.] [p.m.]
Note.—If the person making the above declaration knowingly and wilfully makes therein a statement false in a material particular, he will be guilty of an offence.