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 disability
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 have had a medical emergency that took place after 5pm, on the sixth working day before
the poll which means that you cannot vote in person at your polling station, you can apply to vote by
emergency proxy (someone else voting on your behalf). You can apply 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.
Fill in the proxy vote application form. You must give a reason why you need to vote by proxy and
may need a qualified person to sign your application. See notes on page 2 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.
Page 1 of 6
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
disabled persons
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.
Benefit payments:
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.
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
Application to vote by emergency
proxy based on disability
z
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
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:
D M Y YD M Y Y
4 Why do you want a proxy vote?
Read the notes on the previous page and
complete either A, B or C.
A – I am not able to go to the polling station
on polling day due to the following disability:
B – I am not able to go to the polling
station on polling day due to my blindness.
I am registered blind by (the following
local authority):
C – I am not able to go to the polling station
on polling day due to my disability for which
I am in receipt of a benefit payment. Please
state which of the benefit payments listed on
page 2 you receive and your disability:
5
When did the disability preventing you
from going to the polling station occur?
Time:
Date
D M Y YD M Y Y
Page 3 of 6
D M Y YD M Y Y
Application to vote by emergency
proxy based on disability
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.
If you are unable to sign this form, please
contact your elections team at your council.
Signature: Sign below using black ink,
keeping within the grey border.
7 Date of application
Today’s date
8 Support for this application
D M Y YD M Y Y
Page 4 of 6
Read the notes to see who can support this
application. Please complete either 8A, 8B, 8C,
or 8D on pages 5 - 6:
Complete 8A if you are giving care
and/or treating the disability detailed in the
application, and are:
a registered medical practitioner (including
a dentist, optician, pharmacist, osteopath,
chiropractor or psychologist)
a registered nurse
a registered health professional
Complete 8B
if you are giving care, treatment
and/or have arranged care or assistance
in respect of the disability detailed in the
application and are:
a registered social worker
Complete 8C if you are:
a person registered as running a
residential care home
the warden of premises provided for people
of pensionable age or disabled persons
Complete 8D if you are:
a registered mental health manager or
their representative
The application does not need to be
supported if Part 4B or 4C applies.
Application to vote by emergency
proxy based on disability
8A
If you are giving care and/or treating the
disability detailed in the application,
and are:
a registered medical practitioner, (including
a dentist, optician, pharmacist, osteopath,
chiropractor or psychologist)
a registered nurse
a registered health professional
Supporter’s full name
Supporter’s address
Postcode
Phone number (optional)
Email (optional)
Supporter’s qualification
Declaration:
I am providing care and/or treating the
applicant for the disability specified in
the application
To the best of my knowledge and belief:
– the applicant has the disability specified in
the application and cannot reasonably be
expected to go to their polling station on
polling day or to vote there unaided due
to that disability.
– the disability specified in the application
is likely to continue until after the date of
the poll.
– the applicant became disabled on:
D M Y YD M Y Y
Supporter’s signature
Today’s date
D D M M Y Y Y Y
D M Y YD M Y Y
D M Y YD M Y Y
Page 5 of 6
8B
If you are a registered social worker
giving care, treatment and/or have
arranged care or assistance in
respect of the disability detailed in the
application
Supporter’s full name
Supporter’s address
Postcode
Phone number (optional)
Email (optional)
Supporter’s qualification
Declaration:
I am providing care and/or treating the applicant,
or have arranged care or assistance for the
applicant, for the disability specified in the
application
To the best of my knowledge and belief:
– the applicant has the disability specified in the
application and cannot reasonably be expected
to go to their polling station on polling day or to
vote there unaided due to that disability.
– the disability specified in the application
is likely to continue until after the date of the
poll.
– the applicant became disabled on:
Supporter’s signature
Today’s date
Application to vote by emergency
proxy based on disability
8C
If you are a person registered as running
a residential care home, or the warden
of premises provided for people of
pensionable age or disabled persons
Supporter’s full name
Supporter’s address
Postcode
Phone number (optional)
Email (optional)
Supporter’s qualification
Declaration:
To the best of my knowledge and belief:
– the applicant has the disability specified in
the application and cannot reasonably be
expected to go to their polling station on
polling day or to vote there unaided due
to that disability.
– the disability specified in the application
is likely to continue until after the date of
the poll.
– the applicant became disabled on:
D M Y YD M Y Y
Supporter’s signature
Today’s date
8D
If you are a registered mental health
manager or their representative
Supporter’s full name
D D M M Y Y Y Y
Phone number (optional)
Email (optional)
Supporter’s position at the hospital where the
applicant is receiving treatment
Declaration:
I am authorised to support this application
To the best of my knowledge and belief:
– the applicant has the disability specified in
the application and cannot reasonably be
expected to go to their polling station on
polling day or to vote there unaided due
to that disability.
– the disability specified in the application
is likely to continue until after the date of
the poll.
– the applicant became disabled on:
D M Y YD M Y Y
Supporter’s 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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