Application To Vote By Proxy Form - Tonbridge And Malling Borough Council (Page 4 of 4) in pdf

Reason for your application

You should complete whichever part of this section applies to you. If you are applying just for one

election (Part 7A) you do not need anyone to support your application. Also you do not need anyone

to support your application if you are registered blind or you receive the higher rate of the mobility

component of the disability living allowance (Parts 7B(i) and (ii)). For other reasons you will need to

get someone to support your application.

7A One election only

I am unable to attend my polling station at the election indicated in Part 3 because:

_________________________________________________________________________________

________________

(Please state the reason e.g. “I am away on holiday” etc. You do not need anyone to support your application)

Physical Incapacity

Either:

(i)

I am registered as a blind person by the ____________________________________________Council

Or:

(ii)

Please state which of the benefit payments listed in the latter you receive, and your disability

__________________________________________________________________________________

(Please state the nature of your incapacity)

Or:

(iii)

I suffer from a physical incapacity, which is:

__________________________________________________________________________________

(Please state the nature of your incapacity)

If the address at which you are registered as an elector is a residential care home or sheltered accommodation, then please

tick this box.

Declaration in Support

If you filled in Sections 7B (i) or (ii) you do not need anyone to support your application

I confirm that to the best of my knowledge and belief, the applicant is suffering from the incapacity stated and cannot

reasonably be expected to attend the polling station in person or to vote there unaided. This is likely to continue

*indefinitely / *for the period specified in part 3 overleaf.

If a doctor, a registered nurse or Christian Science practitioner: the applicant is receiving treatment or care from me for the

incapacity stated.

Signed_____________________________________ Name________________________________ Date____________

Address___________________________________________________ *Qualification/* Position ____________________



If the applicant does not live in a residential care home or sheltered accommodation, the declaration must be made by a doctor,

nurse or Christian Science practitioner.



If the applicant lives in a residential care home or sheltered accommodation, the declaration can be signed by (a0 a resident

warden of sheltered accommodation, or a head of home, or a person registered under Part 1 of the Registered Homes Act 1984

as carrying on a residential care home, or (b) a person in charge of local authority residential accommodation.

Occupation or Employment

*I am/* my spouse is * employed by/* attending an education course at _________________________________________

as a: (describe job)____________________________________________________ tick box if self employed

I cannot reasonably be expected to go to my polling station at elections because

__________________________________________________________________________________________________

(Please give reason

Declaration in Support

I certify that to the best of my knowledge and belief the above statement is true

Signed_____________________________________ Name________________________________ Date____________

Address__________________________________________________________ Position _________________________

* This declaration must be signed by a person authorised to sign on behalf of the employer or educational institution concerned. If the

applicant is self-employed, the declaration must be signed by someone who knows the applicant, is 18 years or over, and is not related to

the applicant.

Application To Vote By Proxy Form - Tonbridge And Malling Borough Council Page 4

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