| I, ................................................................................................... (name of companion) |
| | |
| of .................................................................................................. (address of companion) |
| | |
| having been requested to assist ..................................................... (name of voter) |
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| [in the case of a person with disabilities voting as proxy, add |
| | |
| voting as proxy for ........................................................................ (name of elector)] |
| | 15 |
| whose number on the register is .................................................. to record their vote |
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| at the [referendum]* [and]* [National Assembly for Wales elections]* being held in |
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| this [voting area]*/ [constituency]* |
| | |
| | | |
| (a) | [I am entitled to vote as an elector at the said [referendum]* [and]* |
| | 20 |
| | | |
| (b) | [I am the #.................................. of the said voter and have attained the age |
| | |
| | | |
| (c) | I have not previously assisted any voter with disabilities [except |
| | |
| .......................... (name of other elector), of .......................... (address of other |
| | 25 |
| elector)], to vote at the said [referendum]* [or]* [election]*]*. |
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| #State the relationship of the companion to the voter. |
| | |
| | | |
| (Signed) .......................................... (companion) |
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| Date ................................................ |
| | 30 |
| I, the undersigned, being the presiding officer for the .............. polling station for |
| | |
| .............. the [insert name of voting area] hereby certify that the above declaration, |
| | |
| having been first read to the above-named declarant, was signed by the declarant |
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| | | |
| (Signed).......................................... |
| | 35 |
| Date ............................................... |
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