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Candidate/Election agent/Polling
Agent may challenge.
10/19/15
Failure of Challenge
10/19/15
Challenge Proved
10/19/15
Tendered votes
To be issued to an elector in
whose name another person has
already voted as such voter.
10/19/15
Tendered votes
Tendered votes
Disabled to be given
preference
10/19/15
Refused to vote.
10/19/15
10/19/15
11
Closing of Poll
10/19/15
12
the
Move
the
window
cover
clockwise and turn the button
hard in the clockwise direction
until it stops and closes the slit
10/19/15
13
10/19/15
14
Fill in
18
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R - 15
DATE
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APPENDIX V
PRESIDING OFFICERS DIARY
10/19/15
ON
A
6.
7.
From
9.
10/19/15
21
To
11.
Men
(ii)
Women
...
(iii)
...
12.
Total
Challenged Votes:
(i)
Number
allowed
.
10/19/15
RETURNING OFFICER 19 RIVONA
22
14.
Number
of
15.
Number of electors :
Tendered
Votes
age obtained
16.
10/19/15
23
18.
19.
No. of
21.
Was the poll vitiated by(i) Any ballot box used at the PS having
been unlawfully
taken out of the custody
of the Presiding Officer:
Yes
No
(a)
Accidently
or
intentionally
lost
or
destroyed ...................
(ii) The ballot papers having been unlawfully marked by any person & deposited in the
(b)
damaged
or
tampered
with
ballot
box,
please
give
details.
..............................
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25.
26
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2
3
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PART II
ACCOUNT OF PAPER SEALS
Serial number of paper seals supplied from................. To
________________________________________________
2.
Total number supplied
________________________________________________
3.
No. of paper seals used
________________________________________________
4.
No. of paper seals spoiled /damaged
________________________________________________
5.
No. of unused paper seals returned to Returning Officer
________________________________________________
1.
Place:
Date:
10/19/15
28
29
The
Sealed
containing:
Packets
Form No. 9
Account of Paper Seals
10/19/15
30
DATE
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FORM No. 9
[ See rule 47(4)]
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Serial No.
From
1.
2.
3.
4.
5.
6.
Place: ..
Date: ...
1] 1 = 2 +
3
2] 2 = 4
To
Total
________________________
Signature of Presiding Officer
SEALED PACKETS
Containing
Hand
book of Instructions
Presiding Officers
to
Diary.
Cover containing receipt book and
cash, if any.
Any
ADJOURNMENT OF POLL
Natural calamity.
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to
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34
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36
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Certain significant
instructions
ALWAYS BE:
THANKS
AND
ALL THE
BEST
CERTIFICATE
BACK
( Where the roll is reprinted to reflect Deletions & Corrections in the Supplement Nos. 1
5)
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Returning Officer/Asstt.
Officer
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10/19/15
Has
h
Mar
k
Delete
d
PHOTO
AS IN
CORRECTION
CORRECTION
LIST
BACK
ELECTION MATERIAL
BACK
Metal Seal
Distinguishing
Mark
Indelible
Ink
10/19/15
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41
BACK
10 COLVA
The specimen signatures of contesting candidates and their Election Agents are given below for the purpose of
verification of their signatures by the Presiding Officer in the letter of appointment of polling Agents at the time of
poll:-
Specimen
Signature
Specimen
Signature
1.
2.
3.
4.
Date: ..
Place: .
42
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Sr.
No.
Name of Candidate
Address of Candidate
Party
Affiliation*
Symbol
Alloted
1.
2.
3.
4.
5.
6.
Date: ..
43
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BACK
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WARNING NOTICE
45
BACK
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Model Polling
Station
10/19/15
BACK
46
BACK
FORM No. 15
APPOINTMENT OF POLLING AGENT
[ See Rule 27(2) and Rule 29(2) ]
Place: ....
Date: .
10/19/15
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Signature of Candidate
OFF
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47
BACK
Sl. No. _____________
ENTRY PASS
AC No. & Name : ________________________
P.S. No. & Name : ________________________
Name of Candidate
: ________________________
UR
Name of Relief Agents, if any: __________________
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BACK
793
788
125
49
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837
FORM NO. 9
Ballot Paper Account
BACK
_________________________________________________________________________
1. Number of Ballot papers received by the presiding officer at the polling station
2. Number of Ballot papers issued to voters
3. Number of unused Ballot papers returned.
4. Number of Ballot papers cancelled.
RET
5. Number of Ballot papers used as tendered ballot papers.
UR
6. Number of Ballot papers in the ballot box.
NIN
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__________________________________________________________________________
Place: ..
DO NOT INCLUDE TENDERED
Date:
BALLOT PAPERS AT SR. NO.S 1 & 2
Signature of
50
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OFF
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Presiding
ON
A
Officer
FORM NO. 7
List of Challenged Votes
BACK
Signature
Sr. No.
or
Name of Voter thumb
of
in the impression
Voter list of of voter
voters and his
address
1
Name
of
Order of
of
Presiding
identifier,
deposit Officer in
challenging
if any
made each case
Name of
person
Amount
Place: ..
Date:
51
10/19/15
Signature of the
challenger
acknowledging
the receipt of
deposit where
deposit is
returned
8
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Signature of Presiding
Officer
ON
A
FORM NO. 8
List of Tendered Votes
BACK
Sr. No. of
Ward /
Constitu
ency
Address of
Elector
Place: ..
Date:
52
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Signature
or Thumb
impression
of person
tendering
vote
6
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Signature of Presiding
Officer
ON
A
DATE
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FORM No. 9
[ See rule 47(4)]
R - 16
Serial No.
From
1.
2.
3.
4.
5.
6.
Place: ..
Date: ...
1] 1 = 2 +
3
2] 2 = 4
To
Total
________________________
Signature of Presiding Officer
Unsealed Documents
54
10/19/15
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BACK
Election to
I hereby declare
1.
That I have demonstrated to the Polling Agents and other persons present that the Ballot Box to be used for the Poll is empty.
2.
That on the Paper Seal used for securing the Ballot Box, I have affixed my own signature and obtained thereon the signatures of
such of the Polling Agents as are present and desrirous of affixing the same.
3.
That I have demonstrated to the Polling Agents and others present that the Marked Copy of the Electoral Roll to be used during the
poll does not contain any marks other than those used for issuing Postal Ballot Papers and Election Duty Certificate, and
4.
That, I have allowed the Polling agents to note te first and the last of the serial numbers of the Ballot Papers and showed them
bundles of ballot papers which will be used at the Polling Station.
6.
The following Polling Agent(s) declined to affix their Signature(s) on this declaration
7.
8.
BACK
PART - II
Declaration By The Presiding Officer at the time of use of subsequent Ballot Box
Election to
I hereby declare
1.
That I have demonstrated to the Polling Agents and other persons present that the Second/Third/................. Ballot Box to be used
for the Poll is empty and
2.
That on the Paper Seal used for securing the Ballot Box, I have affixed my own signature and obtained thereon the signatures of
such of the Polling Agents as are present and desrirous of affixing the same.
4.
The following Polling Agent(s) declined to affix their Signature(s) on this declaration
5.
6.
BACK
PART - III
Declaration at the End of Poll
I have furnished to the Polling Agents, who were present at the Polling Station at the close of the Poll and
whose signatures are affixed below, an attested copy of each of the entries in Part I Account of Votes
Recorded of Form 9.
Date: ..........................
Time:........................... Signature of Presiding Officer
Received an attested copy of the entries in the Account of Votes Recorded ( Part I of Form 17 C)
Signature of Polling Agents:
1.
2.
3.
The following Polling Agents who were present at the close of the poll declined to receive an attested copy of the
Part I of Form 17C and to give a receipt therefore and so an attested copy of that Form was not supplied to them
4.
5.