Form M-12 - Form of declaration by companion of blind or infirm voter
[See Rule 56A-11(1)]
Form of declaration by companion of blind or infirm voter
Election to the................................ Co-operative Society Ltd .......................
(name of society)
Tahsil................... District.................. from the ....................... constituency.
(name of constituency)
No. and name of Polling Station :
I................................................................... aged............................ residing at . .................................;............................. hereby declare that:-
(a) I wish to act as companion of Shri/Smt............................ who is a blind /infirm voter at the above election and whose name is in the voters list at Sr. No.........
(b) I have not already acted as the companion of any other voter at my polling station on this day.
(c) I will keep secret the vote recorded by me on behalf of the voter aforesaid.
Place :
Date :
Signature of the companion