Fillable Form 1: Application to vote by emergency proxy (East Staffordshire Borough Council)

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Form 1: Application to vote by emergency proxy (East Staffordshire Borough Council)

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Application to vote by emergency proxy
based on disability
How do I apply to vote by proxy?
1
2
3
4
You must ask someone if they are willing and able to be your proxy and vote on your behalf.
Please note that a person can only be the proxy for close relatives and up to two other people
at the same election or referendum*.
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 below for information on
who can support your application.
Make sure you complete all sections of the form and supply your date of birth and signature.
Return your form to your local electoral registration office. You can find their details at
www.aboutmyvote.co.uk.
Only electors who are (or will be) registered individually are entitled to vote by proxy. In addition,
the person you wish to appoint as your proxy can only act as proxy if they are (or will be) registered
individually. Contact your electoral registration office for further information.
Please do not return your form to the Electoral Commission. Please note: this form can only be used after
5pm on the sixth working day before an election or referendum and must arrive at your electoral
registration office before 5pm on the day of the poll.
* By referendum we mean: Neighbourhood Planning Referendums, Council Tax Referendums, Mayoral & Governance Arrangements
Referendums, and Local Authority Advisory polls. If you wish to apply to vote by post for a different type of referendum, please contact
your Electoral Registration Officer.
Application to vote by emergency proxy
based on disability
Voting by proxy
If you have had a medical emergency that took place
after 5pm on the sixth working day before an election
or referendum 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 up until 5pm on polling day.
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.
Does my application need
supporting?
If you are registered blind by a local authority and
your application is based on your blindness, or 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 4B or 4C of
the application.
Benefit payments:
n A higher rate of the mobility component of a
disability living allowance
n The enhanced rate of the mobility component of
the personal independence payment
n An Armed Forces independence payment
Who can support my application?
If they are giving care or treating you for the disability
that prevents you from voting in person (the disability
does not have to be permanent):
n a registered medical practitioner, including
a dentist, optician, pharmacist, osteopath,
chiropractor and psychologist
n a registered nurse
n a registered health professional
If they are giving care, treating you, or have arranged
care or assistance in respect of the disability:
n a registered social worker
Alternatively:
n a registered mental health manager or their
representative
n if you live in a residential care home, the person
registered as running that home
n if you live on premises provided for people of
pensionable age or disabled persons, the warden
of those premises
What happens after I’ve returned
this form?
n Your proxy must go to your polling station
to vote on your behalf.
n You should tell your proxy how you want them
to vote on your behalf, for example, which
candidate, party, or outcome.
n Your local election office will tell your proxy when
and where to vote on your behalf.
n You will 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 Electoral Registration Officer
Voting as proxy
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.
The person you wish to appoint as your proxy can
only act as proxy if they are 18 or over and they are
(or will be) registered individually.
Application to vote by emergency proxy
based on disability
More information
If you have any questions about voting by proxy,
go to www.aboutmyvote.co.uk or contact your
electoral registration office.
In England and Wales, the electoral registration
office is based at your local council. In Scotland,
it may be a separate office. For contact details, go
to www.aboutmyvote.co.uk
This form does not apply in Northern Ireland.
Visit www.eoni.org.uk for more information.
Electoral Registration Officers will only use the
information you provide for electoral purposes.
They will look after personal information securely
and will follow the Data Protection Act 1998.
Electoral Registration Officers will not give personal
information about you to anyone else or another
organisation unless they have to by law.
Application to vote by emergency proxy
based on disability
Only one person can apply to vote by emergency proxy using this form. Write in black ink and use
BLOCK LETTERS. When you have filled in every section and signed the form yourself, send it to your
local electoral registration office. You can get the address at www.aboutmyvote.co.uk
Surname
First names (in full)
Your current full address
Postcode or BFPO
Your correspondence address (if different)
Daytime telephone or mobile number (optional)
E-mail address (optional)
About your proxy
2
Full name
Relationship to you (if any)
Full address
Postcode
At which election do you want a proxy?
About you
1
3
I want to vote by proxy at the election(s) and
referendum(s) held on:
Date
D D M M Y Y Y Y
Why do you want a proxy vote?
4
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
election day due to the following disability:
B – I am not able to go to the polling station on
election 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
election day due to my disability for which I am in
receipt of a benefit payment. Please state which of
the benefit payments listed on the previous page
you receive and your disability:
When did the disability preventing you from
going to the polling station occur?
5
Time
Date
D D M M Y Y Y Y
Application to vote by emergency proxy
based on disability
Only one person can apply to vote by emergency proxy using this form. Write in black ink and use
BLOCK LETTERS. When you have filled in every section and signed the form yourself, send it to your
local electoral registration office. You can get the address at www.aboutmyvote.co.uk
Declaration: I have asked the person I have named
as my proxy and confirm that he/she is willing and
able 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 offence, punishable on
conviction by imprisonment of up to 2 years and/or
a fine.
Date of birth: Please write your date of birth ‘DD MM
YYYY’ in the black boxes below, using black ink.
Signature: Sign below, keeping within the grey border.
If you are unable to sign this form, please contact
your Electoral Registration Officer.
Date of application
7
Today’s date
D D M M Y Y Y Y
Your date of birth and declaration Support for this application
6 8
Read the notes to see who can support this
application. Please complete either A, B, C, or D on
the following pages as appropriate:
Complete A if you are giving care and/or treating the
disability detailed in the application, and are:
n a registered medical practitioner, including
a dentist, optician, pharmacist, osteopath,
chiropractor and psychologist
n a registered nurse
n a registered health professional
Complete B if you are giving care, treatment and/or
have arranged care or assistance in respect of the
disability detailed in the application and are:
n a registered social worker
Complete C if you are:
n a person registered as running a residential care
home
n the warden of premises provided for people of
pensionable age or disabled persons
Complete D if you are:
n a registered mental health manager or their
representative
The application does not need to be supported
if you completed Part 4B or 4C and are applying
due to blindness and you are registered as a blind
person, or if you are in receipt of the higher rate
component of either the disability living allowance or
the personal/Armed Forces independence payment
due to the disability.
Application to vote by emergency proxy
based on disability
Only one person can apply to vote by emergency proxy using this form. Write in black ink and use
BLOCK LETTERS. When you have filled in every section and signed the form yourself, send it to your
local electoral registration office. You can get the address at www.aboutmyvote.co.uk
A If you are giving care and/or treating the disability
detailed in the application, and are:
n a registered medical practitioner, including
a dentist, optician, pharmacist, osteopath,
chiropractor and psychologist
n a registered nurse
n a registered health professional
Supporter’s full name
Supporter’s address
Postcode
Supporter’s qualification
Declaration:
n I am providing care and/or treating the applicant
for the disability specified in the application
n 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
election 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
election.
– the applicant became disabled on
Supporter’s signature
B 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
Supporter’s qualification
Declaration:
n 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
n 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
election 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
election.
– the applicant became disabled on
Supporter’s signature
Date
D D M M Y Y Y Y
Date
D D M M Y Y Y Y
Application to vote by emergency proxy
based on disability
Only one person can apply to vote by emergency proxy using this form. Write in black ink and use
BLOCK LETTERS. When you have filled in every section and signed the form yourself, send it to your
local electoral registration office. You can get the address at www.aboutmyvote.co.uk
C 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
Supporter’s qualification
Declaration:
n 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
election 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 election.
– the applicant became disabled on
Supporter’s signature
D If you are a registered mental health manager or
their representative
Supporter’s full name
Supporter’s position at the hospital where the
applicant is receiving treatment
Declaration:
n I am authorised to support this application
n 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
election 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 election.
– the applicant became disabled on
Supporter’s signature
Date
D D M M Y Y Y Y
Date
D D M M Y Y Y Y
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Form 1: Application to vote by emergency proxy (East Staffordshire Borough Council)

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Completed 1 August 2020

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