Application to vote by emergency
proxy based on disability
Who can support my application?
If they are giving care or treating you for the disability your application can be supported by:
a registered medical practitioner (includes dentist, optician, pharmacist, osteopath, chiropractor or psychologist)
a registered nurse
a registered health professional
If they are giving care, treating you, or have arranged care or assistance in respect of the disability your
application can be supported by:
a registered social worker
Alternatively your application can be supported by:
a registered mental health manager or their representative
the person registered as running the residential care home you live in
the warden of the premises you live in that are provided for people of pensionable age or
If you are registered blind by a local authority and your application is based on your blindness, you do not
need to have your application supported. You must complete part 4B.
If you are in receipt of a benefit payment (listed below) because of the disability specified in the
application, then you do not need to have your application supported. You must complete part 4C.
A higher rate of the mobility component of a disability living allowance
The enhanced rate of the mobility component of the personal independence payment
An armed forces independence payment
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.
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.
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