FORM G
1
3rd Sched. (Part IV)
130
Form of declaration to be made by the companion of a blind elector.
Part III (Paragraph 21(2))
State
relationship
I, A.B., of
requested to assist C.D., who is numbered
on the register of electors for the (
, having been
Ward of the)
Municipality of Hong Kong, to record his vote at the election now
being held for the said (Ward) (Mmicipality) do hereby declare that (I am entitled to vote at the said election) (I am the
of companion of the said elector and have attained the age of twenty-one years) to elector.
and that I have not previously assisted any blind person (except E.F.
af
Dated the
) to vote at the said election.
Signed ................ A.B.
day of
19
I, the undersigned, do hereby certify that I faithfully interpreted
the above declaration to the above-named declarant.
Signed
G.H.
I, the undersigned, being the presiding officer for the
polling station for the (
Ward of the) Municipality of
Hong Kong, do hereby certify that the above declaration, having first
been read to the above named declarant, was signed by the declarant in
my presenos,
Signed
J.K.
The
da
af
19
at
minutes past
o'clock in the
noon.
Note. If the person making the above declaration knowingly
and wilfully makes therein a statement false in a material particular,
he will be guilty of an offence.
(7)
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