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I ......................................................................................
I.C.No ...........................................
(Name in full)
Of ...............................................................................................................................
(Address)
declare that I am the ..................................................................................................
(State relationship)
.............................................................................
I.C.No ...........................................................
(Name of Voter)
who is incapacitated. His Number in the electorall roll is
......................................................................................
I
further declare that I am an elector And that my name appears
in the electoral rolls for the Constituency of ......................................................................................
My
Polling District Code No. is ........................................................................................................................
and my
number in the electoral roll is ................................................................................................................
................................................................
Signature
Declared
before me the......................20..............
............................................................
Presiding Officer
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