FORM 27

[see rule 53A]

DECLARATION BY VOTER FOR USE OF POSTAL BALLOT PAPER

(This side is to be used only when the voter signs the declaration himself)

Election to
Panch of Gram Panchayat ________________________from Ward Number _____
Sarpanch, Gram Panchayat_______________________
Member of Panchayat Samiti ______________________from Ward Number _____
Member of Zila Parishad _________________________ from Ward Number _____

I hereby declare that I am the voter to whom postal ballot paper bearing
serial number _________has been issued at the above election.

Date __________________ Signature of the Voter

Address ________________________
________________________
________________________

ATTESTATION OF SIGNATURE

The above has been signed in my presence by _____________________

(Voter) who is personally known to me/has been identified to my satisfaction by
_____________________________ (Identifier) who is personally known to me.

Signature of the Identifier Signature of the Attesting Officer,

If any _____________________ Designation ______________________
Address ___________________ Address _________________________
__________________________ __________________________
Date ____________________________

(This side is to be used when the voter cannot sign himself)

I hereby declare that I am the voter to whom the postal ballot paper
bearing serial number ______________ has been issued at the above election.

Date _____________________ Signature of Attesting Officer

On behalf of Voter
Address of Voter _________________
________________________________
 CERTIFICATE

I hereby certify that –

(1) The above named voter is personally known to me/has been identified to my
satisfaction by ______________________ (identifier) who is personally known to
me;

(2) I am satisfied that the voter is illiterate/suffers from ________________ (infirmity)

and is unable to record his vote himself or sign his declaration.

(3) I was requested by him to mark the ballot paper and to sign the above declaration
on his behalf; and

(4) The ballot paper was marked and the declaration signed by me on his behalf in
his presence and in accordance with his wishes.

Signature of the Identifier Signature of the Attesting Officer,

If any __________________ Designation ______________________
Address ________________ Address _________________________
_______________________ ________________________________
Date ____________________________