A -  Total number of electorate       ..     ..      ..        ..                ................................

B -  Number of votes cast for :

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

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

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

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

...............................................................................                ..................................
                                                                                                       ______________
                   Total number of votes cast
                                                                                                        ______________

C - Number of rejected ballot papers  ..   ..      ..      ..        ..            .............................

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

E -   Total  number of ballot papers issued at the
        poll (including postal ballot papers issued
         to voters and rejected ballot papers but
         excluding spoilt ballot papers)  ..      ..      ..       ..        ..         ............................

F -  Number of ballot papers issued but not returned
       (including postall ballot papers)  ...        ..       ..                 ............................      

G -  Percentage of voting (E/A x 100)  ..     ..     ..    ..                 ..............................

H -  Majority  ..    ..     ..      ..        ..   ..                                    .............................

I certify that the above statement is correct

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

                                                                      ..................................................
                                                                                     Returning Officer