Fillable Application to vote by emergency proxy based on (Tamworth Borough Council)

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Application to vote by emergency proxy based on (Tamworth Borough Council)

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Application to vote by emergency proxy
based on occupation, service or employment
Voting by proxy
Proxy voting means that if you aren’t able to cast your vote in person, you can have someone you trust cast
your vote for you.
If you are not able to attend the polling station in person for reasons relating to your occupation,
service or employment, and you only become aware of this after 5pm, on the sixth working day before
the poll, you can apply to vote by emergency proxy (someone else voting on your behalf). You can apply up
until 5pm on the day of the poll.
This form should not be used if you have been detained in a hospital under Section 145 of the Mental Health
Act 1983 in England and Wales or Section 329 of the Mental Health (Care and Treatment) (Scotland) Act
2003 in Scotland.
Both you and your proxy must be registered and eligible to vote.
A person can only be a proxy for close relatives and up to two other people at an election or referendum.
Close relatives are the spouse, civil partner, parent, grandparent, brother, sister, child or grandchild of
the applicant.
How do I apply to vote by proxy?
You must ask someone who is willing and capable to be your proxy and vote on your behalf.
Unless you are registered to vote as a service voter or anonymous elector, you must get an appropriate
person to sign your application. See notes below for information on who can support your application.
Make sure all sections of the form are complete and supply your date of birth and signature. You need to give
your date of birth and signature on this application form. This information is needed to prevent fraud. If you
are unable to sign this form, please contact your elections team at your council.
Return your form to your elections team at your council. You can find their details and more information
at electoralcommission.org.uk/voter.
Please do not return your form to the Electoral Commission.
This form can only be used after 5pm, on the sixth working day before the poll and must arrive at your
electoral registration office before 5pm on the day of the poll.
If you are not already registered to vote, you must register before applying for a proxy vote. The deadline to
register to vote is midnight, 12 working days before the poll. Register to vote online at gov.uk/register-to-vote
This form and these deadlines do not apply in Northern Ireland. Visit eoni.org.uk for more information.
Who can support my application?
Your application can be supported by:
an employer or another authorised person at the place of work (if employed)
a person who knows you and is not related to you (if self-employed).
In England, your supporter must be aged 18 or over.
In Scotland, if you are self-employed your supporter must be 16 or over to support your application for local
elections and elections to the Scottish Parliament. They must be 18 or over to support all other applications.
In Wales, if you are self-employed your supporter must be 16 or over to support your application for
Senedd elections. They must be 18 or over to support all other applications.
Your supporter must complete the relevant declaration section 8, 9 or 10.
If you are registered as a service voter (armed forces, Crown servant, British Council employee), you do
not need support for your application.
If you are registered as an anonymous elector you do not need support for your application.
Page 1 of 6
Application to vote by emergency proxy
based on occupation, service or employment
What happens after I’ve returned this form?
Your proxy must go to your polling station to vote.
You should tell your proxy how you want them to vote on your behalf, for example, which candidate,
party, or outcome.
The elections team at your council will tell your proxy when and where to vote on your behalf.
Privacy statement
We collect information under the legal basis of a task carried out in the public interest, as set out in the
Representation of the People Act 1983 and related regulations. We will look after personal information
securely and follow data protection legislation.
If you opted-out of the open register we will only use the information you give us for electoral purposes,
including matching it against other sources of data to support the electoral register. We will not give
personal information to anyone else, unless we have to by law. The law requires us to share your
information with candidates, political parties and campaigners for democratic engagement purposes
and credit reference agencies to check your identity when you apply for credit.
If you have not opted-out of the open register your name and address can be bought by anyone and
used for lots of purposes, including direct marketing.
The Electoral Registration Officer is the Controller. For further information relating to the processing
of personal data you should refer to their privacy notice on their website. You can find their website
address and contact details at electoralcommission.org.uk/voter.
Page 2 of 6
D M Y YD M Y Y
Application to vote by emergency proxy
based on occupation, service or employment
Page 3 of 6
Only one person can apply to vote by emergency proxy using this form
Please write in black ink and use CAPITAL LETTERS. When all sections are complete and you have
signed the form yourself, send it to your elections team at your council. You can find their address at
electoralcommission.org.uk/voter.
1 About you
Surname
First name(s) (in full)
Your address (where you are registered to vote)
Postcode/BFPO
Your correspondence address (if different)
Postcode/BFPO
Phone number (optional)
Email (optional)
Providing an email and phone number gives a
quick and easy way to contact you about your
application.
2
About your proxy (the person you
have chosen to vote on your behalf)
Full name
Family relationship (if any)
Full address
Postcode
Phone number (optional)
Email (optional)
3
At which election(s) and referendum(s)
do you want a proxy?
I want to vote by proxy at the election(s) and
referendum(s) held on:
Application to vote by emergency proxy
based on occupation, service or employment
4
Your employment details and reason
you can’t vote in person
Complete only one of the relevant sections.
4A – I am self-employed as (give job title):
D D M M Y Y Y Y
I am not able to go to the polling station on
polling day for the following reason related to
my occupation:
4B – I am employed by (give employer’s
name and address):
As (give job title):
D D M M Y Y Y Y
I am not able to go to the polling station on
polling day for the following reason related to
my employment:
4C – Tick the type of service voter that applies:
I am a member of the armed forces
I am a Crown servant
I am a British Council employee
I am the spouse or civil partner of a
service voter
I am the child of a service voter
I am not able to go to the polling station on
polling day for the following reason related
to my service (or that of my spouse, civil
partner or parent or guardian):
5
When did you become aware of
the reason?
Time:
Date
6 Your date of birth and declaration
Declaration: I have asked the person I have
named as my proxy and confirm that they are
willing and capable to be appointed to vote on
my behalf.
As far as I know, the details on this form are
true and accurate. I understand that to provide
false information on this form is an of fence,
punishable on conviction by imprisonment of
up to two years and/or a fine.
Date of birth: Please write your date of birth
in the boxes below using black ink.
Signature: Sign below using black ink,
keeping within the grey border.
If you are unable to sign this form, please
contact your elections team at your council.
7 Date of application
Today’s date
D D M M Y Y Y Y
Page 4 of 6
D M Y YD M Y Y
D M Y YD M Y Y
Application to vote by emergency proxy
based on occupation, service or employment
Page 5 of 6
Support for your application
Read the notes to see who can support your application.
Your supporter should now complete the relevant declaration.
If you are registered to vote as a service voter or as an anonymous elector, you do not need support for
your application.
8
Supporter’s declaration (if the
applicant is self-employed)
Supporter’s full name
Supporter’s address
Postcode
Phone number (optional)
Email (optional)
Declaration:
I am aged 18 years or over
I know the applicant
I am not the spouse, civil partner, parent,
grandparent, brother, sister
, child or
grandchild of the applicant
I confirm that to the best of my knowledge
and belief, the applicant’s statements in
Parts 4A and 5 are true
Signature
Today’s date
9
Employer’s declaration (if the
applicant is employed)
Supporter’s full name
Supporter’s address
Postcode
Phone number (optional)
Email (optional)
Supporter’s position with the employer
Declaration:
I am the applicant’s employer or an employee
with authority to act for the employer
I confirm that to the best of my knowledge
and belief, the applicant’s statements in
Parts 4B and 5 are true
Signature
Today’
s date
Application to vote by emergency proxy
based on occupation, service or employment
Declaration by a 16 or 17 year old supporter in Scotland or Wales.
(In Scotland, only valid for local elections and elections to the Scottish
Parliament. In Wales, only valid for Senedd elections).
10
Declaration by 16 or 17 year old supporter (if the applicant is self-employed)
Supporter’s full name
Supporter’s address
Postcode
Phone number (optional)
Email (optional)
Declaration:
I am 16 or 17 years old
I know the applicant
I am not the spouse, civil partner, parent,
grandparent, brother, sister, child or
grandchild of the applicant
I confirm that to the best of my knowledge and
belief, the applicant’s statements in Parts 4A
and 5 are true.
Signature
Today’s date
D M Y YD M Y Y
Page 6 of 6
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Application to vote by emergency proxy based on (Tamworth Borough Council)

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Completed 6 February 2021

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