Form of declaration to be made by the companion of a blind voterU.K.
*State the relationship of the companion to the voter.U.K.
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.) whose number on the register is to record his vote at the election now being held in this constituency, hereby declare that [I am entitled to vote as an elector at the said election] [I am the * of the said voter and have attained the age of 18 years], and that I have not previously assisted any blind person [except E. F., of ] to vote at the said election.
(Signed) A. B.,
day of 19 .
I, the undersigned, being the presiding officer for the polling station for the Consitiuency, 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 .
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.