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Election in the....................................................................................................constituency
[F1 or................................................................................[F2 district electoral area]],
F2SI 1985/454
Date of publication of notice of election........................................................................................................................
I hereby declare that—
1. I am the person [ or a director, general manager, secretary or other like officer of the association or body of persons] named as incurring expenses in the accompanying return, marked........................................, of expenses required by section forty-one of the Electoral Law Act (Northern Ireland), 1962, to be authorised by an election agent.
2. To the best of my knowledge and belief the said return is complete and correct.
3. The matters for which the expenses referred to in the said return were incurred were as follows................................................................................
Signature of declarant............................................................
Office held by declarant................................................................................
(in the case of an association or body of persons)
Date........................................