FROM___________(NUMBER) & __________________________________________(Name of Assembly

Segment) within 17-KHAMMAM PARLIAMENTARY CONSTITUENCY

FORM M 21 – RECEIPT OF RETURN OF ELECTION RECORDS AND MATERIAL AFTER POLL

MATERIAL TO BE HANDED OVER AT RECEPTION CENTER

SPECIAL COUNTER

Number & name of the Polling station:__________________________________

Name of the Presiding Officer with contact Number:__________________________
Sl. Description of Material
No.
A The sealed electronic voting machine (s)
Number of sealed CU Nos.
Number of sealed BUs Nos.
To be
Number of sealed VVPAT Nos.
sent to
First packet --EVM papers EVM
i) Unsealed cover containing the account of Votes recorded 01 strong
(Form 17C) room
ii) Unsealed cover containing the presiding officer report 01
including – I (Mock Poll certificate), II, III,
Part IV & V to be submitted by the Sector Officer if
EVM replacement happens. If not, nil report will be
submitted by the Presiding Officer.
iii) Printed VVPAT paper slips of mock poll (Kept in black
coloured sealed envelope)

Second Packet--Scrutiny Cover

i) Unsealed envelope containing the Presiding Officers diary 02
ii) Sealed Envelope containing the Register of Voters (17A) 01
To be
iii) Unsealed envelope containing visit sheet 01
kept in
iv) Unsealed envelope containing the blind and infirm electors in 01
sealing
Form-14 – A and the Declarations of the companions
room
v) Unsealed cover containing the account of Votes recorded 02
(Form 17C) adjacent
vi) Unsealed cover containing the presiding officer report 01 to EVM
including – I (Mock Poll certificate), II, III, Strong
Part IV & V to be submitted by the Sector Officer if EVM room.
replacement happens. If not, nil report will be submitted by
the Presiding Officer.

SIGNATURE OF THE P.O. SIGNATURE OF THE RECEIVER

/COUNTER INCHARGE.