STATEMENT OF VOTES
Electoral division of .........................................
Polling subdivision No. .....
I, the undersigned, deputy returning officer, certify that at
the election held this day of a Member to serve in the National
Assembly, the candidates listed below received the number of
votes set opposite their respective names:
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. Name of candidate . Number of votes .
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. ................................ . ....................... .
. ................................ . ....................... .
. ................................ . ....................... .
. ................................ . ....................... .
. ................................ . ....................... .
. ................................ . ....................... .
. ................................ . ....................... .
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and also that:
...................... ballot papers were rejected in counting
(number in letters)
the ballots.
bl.
Given under my hand, at ....................................,
this ................................................... 19....
.............................
Deputy Returning Officer
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1984, c. 51, Schedule H.