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Commissioners Clauses Act 1847
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Are you the person assessed as A.B., on the [ ] rate [specifying the rate which confers the right to vote], in respect of property described to be situated in [here specify the street, &c. as described in the rate]
Or, if the voter claim to vote as the owner of property,
Are you the person described as the owner of the property mentioned in [ ] rate [specifying the rate], and described as being situated in [here specify the street, &c. as described in the rate]
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