Situation of Polling Station .................................... Polling Station No ........................

Polling District Code No.............................................................................................

Constituency of........................................................................................................

A -  Total number of ballot papers to be accounted for in the ballot box
        (as in E in Form 13)    ..      ..        ..       ..       ..                          ......................
 
 

B - Number of votes cast for :

                                Name of Candidate                                        Number
 
................................................................................           ................................

................................................................................           ................................

................................................................................            ...............................

................................................................................            ..............................

................................................................................            ..............................

................................................................................            ...............................

................................................................................             ..............................

                                                                                              _______________
 
                                               Total number of votes cast ..
                                                                                              _______________

C - Numbers of rejected ballot papers  ..        ..                 ..............................

D-  Total number of ballot papers in the ballot boxes
      (B+C)   ..       ..        ..          ..          ..                          ..............................
 
 

 E -  Total number of ballot papers issued but
        not returned (A-D)   ..       ..          ..                           ..................................
 
 

I certify that the above statement is correct
 

Dated the...................................................20................

                                                                                 .............................................
                                                                                            Signature and name of
                                                                                                     Presiding Officer

 
                       Signature of   Candidates        }    ....................................................
                        or their election agents           }
                        or counting agents                  }      .................................................
                                                                     }
                                                                     }    ...................................................