Electoral ListCity (or Town) of ................... Ward no ...............============================================================== . . Number of. . . . . . building . Surname. . . No. Street. and . and . Occupation. Age. Qualification . . apartment. Given . . . . . or of . Names . . . . . cadastre . . . . --.-------.----------.--------.-----------.----.--------------1 . . . . . . . . . . . . 2 . . . . . . . . . . . . 3 . . . . . . -------------------------------------------------------------- Made at ....................., on ...................... Place Date We, the undersigned, certify that so far as we haveparticipated in its making the foregoing list is correct to thebest of our knowledge and that nothing has been illegally orfraudulently entered therein or omitted therefrom. So help usGod! Sworn before me, ............................ Returning-Officer at ........................ .............................. Enumerator on ........................ .............................. EnumeratorA. B. justice of the peace.