ELECTORAL REGULATIONS, 2005 Form V. 27 Special Vote Reconciliation Form Section 64(1) (c) of the Electoral Act [Chapter 2:13] To be completed and distributed as follows: One to be sealed in the ballot box. One to be submitted to Chief Elections Officer. Polling Station Return Name of Polling District Station ………………………………………… .. District ……………………………………………….. Province ………………………………………………………………….. Ballot envelopes received (Before Poll) PART A : BALLOT ENVELOPES ACCOUNT Total Ballot envelopes accounted for 1. No. of ballot envelopes used/claimed after 1st day of poll Total ballot papers received 2. No of ballot envelopes used/unclaimed after 2nd day of poll Total 3. No of ballot envelopes not used/unclaimed after the 2 polling days Total (Used/claimed+unuclaimed ballot envelopes) I hereby certify that the above is a correct statement of all ballot papers received by me. FULL NAMES…………………………………………… (Signed)………………………………….. (District Special vote Officer) FULL NAMES…………………………………………… (Signed)………………………………….. (Witness-Polling Officer) Dated this---------------------------------- day of--------------------------------------,20---------- 37 Total