I, A. B., of    , having been requested to assist C. D., (in the case of a F2voter with disabilities 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 F3voter with disabilities [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.]

F4NOTE 1.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.

F5 2. A voter with disabilities is a voter who has made a declaration under the parliamentary elections rules that he is so incapacitated by his blindness or other incapacity, or by his inability to read, as to be unable to vote without assistance.