Western Australian Consolidated Regulations

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ELECTORAL REGULATIONS 1996 - SCHEDULE 3

Form 1

Western Australia

Electoral Act 1907 (s. 22)

FORM OF ELECTORAL ROLL

Roll of electors for the .............................................................................. District and that part of the ..................................................................................... Region in that District.


        Surname         Christian or         Residence         Occupation*         Sex*
                given names


[* This column may be omitted when rolls are printed under section 24 of the Act, made available under section 25 of the Act or supplied under section 112 of the Act or when information on rolls or other information relating to electors is provided or made available under section 25B or 25C of the Act.]

        [Form 1 amended in Gazette 8 Nov 1996 p. 6269; 20 Oct 2000 p. 5929; 11 May 2007 p. 1997.]

Form 2

Western Australia

Electoral Act 1907 (s. 42)

CLAIM FOR ENROLMENT

1 

Surname
or
family name


All Christian
or
given names





2 

Address





Postcode



Shire






3 

Daytime phone number (if convenient)












4 

Postal
address





Postcode


5 

Occupation


 6 

Male □
Female □


7 

Date of birth

Day Month Year

 8 

Town of
birth





9 

Place of birth



10 

I am an Australian citizen

NO □
YES □ ►


If you are an Australian citizen by naturalisation please supply the following details:

Date of Citizenship
naturalisation Certificate No.





Day Month Year





11 

Former surname
or
family name


Former Christian
or given names



12 

Former
address





Postcode


 DECLARATION

I am eligible to enrol for Western Australian elections.
I declare that all the information I have given on this form is true and complete.

Signature or mark of applicant



Date

Day Month Year


 WITNESS 

I saw the applicant sign this form.


Signature of witness


Name
BLOCK

LETTERS


Address


Form 3

Western Australia

Electoral Act 1907 (s. 44A(3)(a))

NOTICE OF REJECTION OF CLAIM

To ........................................................................................... :

I wish to advise that your claim dated .................................... to have your name placed on the roll for the State Electoral District of .................................. and the related part of the .......................................................... Region does not comply with section 44 of the Electoral Act 1907 for the following reasons:

.................................................................................................................................

.................................................................................................................................

.................................................................................................................................


Therefore, your claim is rejected.



......................................................................
ENROLMENT OFFICER

......................................................................
Date

        [Form 3 inserted in Gazette 10 Nov 2000 p. 6170‑1.]

Form 4

Western Australia

Electoral Act 1907 (reg. 22)

DECLARATION BY A PERSON ALLEGED TO HAVE FAILED TO COMPLY WITH THE COMPULSORY ENROLMENT PROVISIONS OF SECTION 45 OF THE ELECTORAL ACT

I, ............................................................ of ............................................................
....................................................................... declare that* ...................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................

Signed: ..................................................

Date: ..................................................

Declared before me:

............................................................................
An elector or a person qualified to be an
elector for the Commonwealth or the State

............................................................................
Address of witness

* Set out any facts which you believe should be taken into account in dealing with the alleged offence.

Form 5

Western Australia

Electoral Act 1907 (s. 47(3)(a))

ENROLMENT OFFICER’S OBJECTION TO CLAIM

To ........................................................................................... :

I refer to your claim dated ....................................... to be enrolled as an elector for the State Electoral District of ................................................. and advise that I believe that you are not entitled to be so enrolled for the following reasons:

.................................................................................................................................

.................................................................................................................................

.................................................................................................................................

Unless the attached notice of appeal (Form 6) is completed and signed by you and returned to me within .................................. days from the date of this notice, your claim will be rejected.


.........................................................................
ENROLMENT OFFICER

.........................................................................
Date

        [Form 5 inserted in Gazette 10 Nov 2000 p. 6171.]

Form 6

Western Australia

Electoral Act 1907 (s. 47(3)(a))

APPEAL AGAINST OBJECTION TO CLAIM


To the Enrolment Officer:


District


Surname


Given names


Residential Address

Street No.


Street Name


Suburb


Postcode


Phone numbers

(Home)

(Work)

Fax number


E‑mail


I wish to appeal against your objection to my claim for enrolment as an elector for the State Electoral District of ............................................................ for the following reasons:

..............................................................................................................................

..............................................................................................................................

..............................................................................................................................

..............................................................................................................................

..............................................................................................................................

..............................................................................................................................

..............................................................................................................................

..............................................................................................................................

..............................................................................................................................

Signature of Claimant

Date

        [Form 6 inserted in Gazette 10 Nov 2000 p. 6172.]

Form 7

Western Australia

Electoral Act 1907 (s. 48(2)(a))

ELECTOR’S OBJECTION TO ENROLMENT

To the Electoral Commissioner:


District


Surname


Given names


Residential Address

Street No.


Street Name


Suburb


Postcode


Phone numbers

(Home)

(Work)

Fax number


E‑mail


I wish to object to the name of ............................................................ being on the roll for the State Electoral District of ............................................................ for the following reasons:

..............................................................................................................................

..............................................................................................................................

..............................................................................................................................

..............................................................................................................................

..............................................................................................................................

..............................................................................................................................

..............................................................................................................................

..............................................................................................................................

..............................................................................................................................

I enclose a deposit of $2.00

Signature of Objector

Date

        [Form 7 inserted in Gazette 10 Nov 2000 p. 6173.]

Form 8

Western Australia

Electoral Act 1907 (s. 48(3)(a))

ENROLMENT OFFICER’S OBJECTION TO ENROLMENT

To: ........................................................................................... :

You are currently enrolled on the State Electoral roll for the State Electoral District of ................................... . However, your enrolment is objected to because I have the following reasons for believing that your name should not be retained on the roll:

.................................................................................................................................

.................................................................................................................................

.................................................................................................................................

Unless the attached notice of appeal (Form 9) is completed and signed by you and returned to me within .................................... days of the date of this notice, your name will be removed from the State Electoral Roll.



.........................................................................
ENROLMENT OFFICER

.........................................................................
Date

        [Form 8 inserted in Gazette 10 Nov 2000 p. 6174.]

Form 9

Western Australia

Electoral Act 1907 (s. 48(3)(a))


NOTICE OF APPEAL AGAINST ENROLMENT OFFICER’S OBJECTION TO ENROLMENT


To the Enrolment Officer:


District


Surname


Given names


Residential Address

Street No.


Street Name


Suburb


Postcode


Phone numbers

(Home)

(Work)

Fax number


E‑mail


I wish to appeal against your objection to the retention of my name on the roll for the State Electoral District of ............................................................ for the following reasons:

.........................................................................................................................

.........................................................................................................................

.........................................................................................................................

.........................................................................................................................

.........................................................................................................................

.........................................................................................................................

.........................................................................................................................

.........................................................................................................................

.........................................................................................................................

Signature of Elector

Date

        [Form 9 inserted in Gazette 10 Nov 2000 p. 6175.]

Form 10

Western Australia

Electoral Act 1907 (s. 51B(1), (2))

        REQUEST BY AN ELECTOR FOR         ADDRESS NOT TO BE SHOWN ON         ELECTORAL ROLL
        Please do not show my address on the         electoral roll

1 

SURNAME or FAMILY NAME ................

ALL CHRISTIAN or GIVEN NAMES .......


2 

RESIDENTIAL ADDRESS ........................


3 

DAYTIME PHONE NUMBER for contact (if convenient) ............................................


4 

POSTAL ADDRESS ..................................
If this address is the same as shown at 2, print “ AS ABOVE ”



Postcode

5 

OCCUPATION ..........................................


6 

SEX .............................................................

□ Male □ Female

7 

DATE OF BIRTH ......................................

Day Month Year

8 

I REQUEST THAT MY ADDRESS ..........
(Please tick the appropriate box)

NOTE: A statutory declaration must be completed attesting to the existence of the risk(s) claimed and forwarded with this application. That declaration may be made by the elector or some other person able to attest to the facts.

(a) □         not be entered on the electoral roll.         An Electoral Enrolment Form         claiming enrolment for my address         is attached;

        OR

(b) □         be removed from the electoral roll.


Having my address shown on the electoral roll places the personal safety of myself or members of my family at personal risk.



9 

I ALSO REQUEST THAT MY NAME BE OMITTED WHEN THE ROLL IS MADE AVAILABLE UNDER SECTION 25 OR 25B OF THE ACT

(Tick the box if required)

        □



10 0

I ALSO APPLY TO BE REGISTERED AS A GENERAL EARLY VOTER UNDER SECTION 93 OF THE ACT

(Tick the box if required)

        □


.....................................................................
Signature or mark of applicant
(Not required if applicant makes the declaration below. Please ensure that the declaration is made before this application is sent to the Electoral Commissioner)



Statutory declaration as to risk

I solemnly and sincerely declare that the risk referred to in  8  above is as follows:

................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................

And I make this declaration by virtue of section 106 of the Evidence Act 1906.

................................................................
Signature of declarant


Declared at .................................................................................................... this .....................
day of .............................................................................................................before me

...................................................................
Commissioner for Declarations
Justice of the Peace
Police Officer
or other person authorised by
the Declarations and Attestations
Act 1913

        [Form 10 amended in Gazette 10 Nov 2000 p. 6176‑7; 11 May 2007 p. 1998.]

Form 11

Western Australia

Electoral Act 1907 (s. 56(a))

NOTIFICATION OF DEATHS OF PERSONS NOT UNDER 17
FOR MONTH OF ...................................

Surname .................................................................................................................

Given name ............................................................................................................

Date of birth ...........................................................................................................

Late address ...........................................................................................................

Age and sex ...........................................................................................................

Date of death .........................................................................................................

Late occupation......................................................................................................

(repeated as necessary)

..............................................................
Registrar General

        [Form 11 amended in Gazette 10 Nov 2000 p. 6175.]

[Form 12 deleted in Gazette 10 Nov 2000 p. 6175.]

[Form 13 deleted in Gazette 12 Dec 1997 p. 7259.]

[Forms 14 and 15 deleted in Gazette 11 May 2007 p. 1998.]

Form 16

Western Australia

Electoral Act 1907 (s. 64(1) and 69)

WRIT

Writ for elections in all the electoral districts to elect members of the Legislative Assembly

To the Electoral Commissioner:

I direct you to proceed with elections in all the electoral districts to elect one member of the Legislative Assembly for each district.

I fix the following days for the purposes of each of those elections:

        Last day for the nomination of candidates:

        ............... day, .......................................................... 20..........

        Polling day:

        Saturday, .................................................................. 20..........

        Last day for the return of the writ:

        ............... day, ........................................................... 20..........




Dated ..................................... 20.....         .............................................................
        Governor

(Reverse)

Certificate

I certify that the results of the elections held under this writ were as follows:


Electoral district         Elected candidate         Date of declaration

.....................................         ........................................         ...................................

[continue for each district]


Dated ........................................... 20 .....         .......................................................
        Electoral Commissioner

        [Form 16 inserted in Gazette 20 Oct 2000 p. 5930‑1.]

Form 17

Western Australia

Electoral Act 1907 (s. 64(2) and 69)

WRIT

Writ for elections in all the electoral regions to elect members of the Legislative Council

To the Electoral Commissioner:

I direct you to proceed with elections in all the electoral regions to elect 6 members of the Legislative Council for each of the electoral regions known, respectively, as the Agricultural Region, the East Metropolitan Region, the Mining and Pastoral Region, the North Metropolitan Region, the South Metropolitan Region and the South West Region.

I fix the following days for the purposes of each of those elections:

        Last day for the nomination of candidates:

        ............... day, .......................................................... 20..........

        Polling day:

        Saturday, ................................................................. 20..........

        Last day for the return of the writ:

        ............... day, .......................................................... 20..........



Dated .......................................... 20 ....         ........................................................
        Governor

(Reverse)

Certificate

I certify that the results of the elections held under this writ were as follows:


Electoral region         Elected candidates         Date of declaration

......................................         ........................................         ...................................

        ........................................

        ........................................

        ........................................

        ........................................

[continue for each region]


Dated ........................................ 20 ......         .......................................................
        Electoral Commissioner

        [Form 17 inserted in Gazette 20 Oct 2000 p. 5931‑2; amended in Gazette 21 Nov 2008 p. 4922.]

Form 18

Western Australia

Electoral Act 1907 (s. 67(1) and 69)

WRIT

Writ for an election in an electoral district to elect a member of the Legislative Assembly to fill a vacancy in accordance with a resolution of that House

To the Electoral Commissioner:

I, ..............................................., the Speaker of the Legislative Assembly, acting upon a resolution passed by the Legislative Assembly under section 67(1) of the Electoral Act 1907 on .................................. 20......, direct you to proceed with an election in the ......................................... electoral district to elect a member of the Legislative Assembly for that district.

I fix the following days for the purposes of that election:

        Last day for the nomination of candidates:

        ............... day, .......................................................... 20..........

        Polling day:

        Saturday, ................................................................. 20..........

        Last day for the return of the writ:

        ............... day, .......................................................... 20..........




Dated .........................................         .............................................................
        Speaker

(Reverse)

Certificate

I certify that the result of the election held under this writ was as follows:


Elected candidate                 Date of declaration

.....................................                 ...................................


Dated .......................................... 20 .......         .......................................................
        Electoral Commissioner

        [Form 18 inserted in Gazette 20 Oct 2000 p. 5933‑4.]

Form 19

Western Australia

Electoral Act 1907 (s. 67(2) and 69)

WRIT

Writ for an election in an electoral district to elect a member of the Legislative Assembly to fill a vacancy as directed by the Speaker

To the Electoral Commissioner:

I, ..............................................., the Speaker of the Legislative Assembly, acting under section 67(2) of the Electoral Act 1907 , direct you to proceed to supply with an election in the ................................................ electoral district to elect a member of the Legislative Assembly for that district.

I fix the following days for the purposes of that election:

        Last day for the nomination of candidates:

        ............... day, .......................................................... 20..........

        Polling day:

        Saturday, ................................................................. 20..........

        Last day for the return of the writ:

        ............... day, .......................................................... 20..........




Dated .......................................... 20 .......         .......................................................
        Speaker

(Reverse)

Certificate

I certify that the result of the election held under this writ was as follows:


Elected candidate                 Date of declaration

.....................................                 ...................................


Dated .......................................... 20 .......         .......................................................
        Electoral Commissioner

        [Form 19 inserted in Gazette 20 Oct 2000 p. 5934‑5.]

Form 20

Western Australia

Electoral Act 1907 (s. 67(3) and 69)

WRIT

Writ for an election in an electoral district to elect a member of the Legislative Assembly to fill a vacancy if there is no Speaker or the Speaker is absent

To the Electoral Commissioner:

I direct you to proceed with an election in the ........................................ electoral district to elect a member of the Legislative Assembly for that district.

I fix the following days for the purposes of that election:

        Last day for the nomination of candidates:

        ............... day, .................................................... 20..........

        Polling day:

        Saturday, ........................................................... 20..........

        Last day for the return of the writ:

        ............... day, ................................................... 20..........




Dated .................................................         .......................................................
        Governor

(Reverse)

Certificate

I certify that the result of the election held under this writ was as follows:


Elected candidate                 Date of declaration

.....................................                 ...................................


Dated ...................................... 20 .......         .......................................................
        Electoral Commissioner

        [Form 20 inserted in Gazette 20 Oct 2000 p. 5935‑6.]

Form 21

Western Australia

Electoral Act 1907 (s. 156E and 69)

WRIT

Writ for an election in an electoral region to elect a member of the Legislative Council to fill a vacancy

To the Electoral Commissioner:

I direct you to proceed with an election in the ........................................ electoral region to elect a member of the Legislative Council for that region.

I fix the following days for the purposes of that election:

        Last day for the nomination of candidates:

        ............... day, .......................................................... 20..........

        Polling day:

        Saturday, ................................................................. 20..........

        Last day for the return of the writ:

        ............... day, .......................................................... 20..........




Dated ...................................... 20 .......         .......................................................
        Governor

(Reverse)

Certificate

I certify that the result of the election held under this writ was as follows:


Elected candidate                 Date of declaration

.....................................                 ...................................


Dated ...................................... 20 .......         .......................................................
        Electoral Commissioner

        [Form 21 inserted in Gazette 20 Oct 2000 p. 5936‑7.]

Form 22

Western Australia

Electoral Act 1907 (s. 88(2) and 69)

WRIT

Writ for a new election in an electoral district when an election is deemed to have wholly failed under section 88(2)

To the Electoral Commissioner:

I direct that, in place of the election fixed for .................................. 20..........., you proceed with a new election in the ............................................... electoral district to elect a member of the Legislative Assembly for that district.

I fix the following days for the purposes of that election:

        Last day for the nomination of candidates:

        ............... day, .......................................................... 20..........

        Polling day:

        Saturday, ................................................................ 20..........

        Last day for the return of the writ:

        ............... day, ......................................................... 20........




Dated ...................................... 20 .......         .......................................................
        Governor/Speaker

        [as the case requires]

(Reverse)

Certificate

I certify that the result of the election held under this writ was as follows:


Elected candidate                 Date of declaration

.....................................                 ...................................


Dated ...................................... 20 .......         .......................................................
        Electoral Commissioner

        [Form 22 inserted in Gazette 20 Oct 2000 p. 5938‑9.]

Form 23

Western Australia

Electoral Act 1907 (s. 88(2) and 69)

WRIT

Writ for a new election in an electoral region when an election is deemed to have wholly failed under section 88(2)

To the Electoral Commissioner:

I direct that, in place of the election fixed for ................................... 20..........., you proceed with a new election in the ............................................... electoral region to elect ........ member(s) of the Legislative Council for that region.

I fix the following days for the purposes of that election:

        Last day for the nomination of candidates:

        ............... day, .......................................................... 20..........

        Polling day:

        Saturday, ................................................................ 20..........

        Last day for the return of the writ:

        ............... day, ......................................................... 20..........




Dated ...................................... 20 .......         .......................................................
        Governor

(Reverse)

Certificate

I certify that the result of the election held under this writ was as follows:


Elected candidate(s)                 Date of declaration

.....................................                 ...................................
[continue as required]


Dated ...................................... 20 .......         .......................................................
        Electoral Commissioner

        [Form 23 inserted in Gazette 20 Oct 2000 p. 5939‑40.]

Form 23A

Western Australia

Electoral Act 1907 (s. 89(1) and 69)

WRIT

Writ for a supplementary election in an electoral district when an election is deemed to have wholly failed under section 89(1)

To the Electoral Commissioner:

I direct that, because of the failure of the election fixed for ................................... 20........., you proceed with a supplementary election in the ............................................... electoral district to elect a member of the Legislative Assembly for that district.

I fix the following days for the purposes of that election:

        Last day for the nomination of candidates:

        ............... day, .......................................................... 20..........

        Polling day:

        Saturday, ................................................................. 20..........

        Last day for the return of the writ:

        ............... day, .......................................................... 20..........




Dated ...................................... 20 .......         .......................................................
        Governor/Speaker
        [as the case requires]

(Reverse)

Certificate

I certify that the result of the election held under this writ was as follows:


Elected candidate                 Date of declaration

.....................................                 ...................................


Dated ...................................... 20 .......         .......................................................
        Electoral Commissioner


        [Form 23A inserted in Gazette 20 Oct 2000 p. 5940‑1.]

Form 23B

Western Australia

Electoral Act 1907 (s. 89(1) and 69)

WRIT

Writ for a supplementary election in an electoral region when an election is deemed to have wholly failed under section 89(1)

To the Electoral Commissioner:

I direct that, because of the failure of the election fixed for ................................... 20..........., you proceed with a supplementary election in the ............................................... electoral region to elect ........ member(s) of the Legislative Council for that region.

I fix the following days for the purposes of that election:

        Last day for the nomination of candidates:

        ............... day, .......................................................... 20..........

        Polling day:

        Saturday, .................................................................. 20..........

        Last day for the return of the writ:

        ............... day, .......................................................... 20........




Dated ...................................... 20 .......         .......................................................
        Governor

(Reverse)

Certificate

I certify that the result of the election held under this writ was as follows:


Elected candidate(s)                 Date of declaration

.....................................                 ...................................
[continue as required]


Dated ...................................... 20 .......         .......................................................
        Electoral Commissioner

        [Form 23B inserted in Gazette 20 Oct 2000 p. 5941‑2.]

Form 23C

Western Australia

Electoral Act 1907 (s. 89(2) and 69)

WRIT

Writ for a supplementary election in an electoral region when an election is deemed to have partially failed under section 89(2)

To the Electoral Commissioner:

I direct that, because of the partial failure of the election held on .................................. 20..........., you proceed with a supplementary election in the ............................................... electoral region to elect ........ member(s) of the Legislative Council for that region.

I fix the following days for the purposes of that election:

        Last day for the nomination of candidates:

        ............... day, .......................................................... 20..........

        Polling day:

        Saturday, ................................................................. 20..........

        Last day for the return of the writ:

        ............... day, .......................................................... 20..........




Dated ...................................... 20 .......         .......................................................
        Governor

(Reverse)

Certificate

I certify that the result of the election held under this writ was as follows:


Elected candidate(s)                 Date of declaration

.....................................                 ...................................
[continue as required]


Dated ...................................... 20 .......         .......................................................
        Electoral Commissioner

        [Form 23C inserted in Gazette 20 Oct 2000 p. 5943‑4.]

Form 23D

Western Australia

Electoral Act 1907 (s. 172(1)(c) and 69)

WRIT

Writ for a new election in an electoral district when an election has been declared absolutely void

To the Electoral Commissioner:

I direct that, because of the election held on .................................. 20..........., being declared absolutely void, you proceed with a new election in the ............................................... electoral district to elect a member of the Legislative Assembly for that district.

I fix the following days for the purposes of that election:

        Last day for the nomination of candidates:

        ............... day, .......................................................... 20..........

        Polling day:

        Saturday, ................................................................ 20..........

        Last day for the return of the writ:

        ............... day, ......................................................... 20..........




Dated ...................................... 20 .......         .......................................................
        Governor/Speaker
        [as the case requires]

(Reverse)

Certificate

I certify that the result of the election held under this writ was as follows:


Elected candidate                 Date of declaration

.....................................                 ...................................



Dated ...................................... 20 .......         .......................................................
        Electoral Commissioner

        [Form 23D inserted in Gazette 20 Oct 2000 p. 5945‑6.]

Form 23E

Western Australia

Electoral Act 1907 (s. 172(1)(c) and 69)

WRIT

Writ for a new election in an electoral region when an election has been declared absolutely void

To the Electoral Commissioner:

I direct that, because of the election held on .................................. 20..........., being declared absolutely void, you proceed with a new election in the ............................................... electoral region to elect ........ member(s) of the Legislative Council for that region.

I fix the following days for the purposes of that election:

        Last day for the nomination of candidates:

        ............... day, .......................................................... 20..........

        Polling day:

        Saturday, ................................................................. 20..........

        Last day for the return of the writ:

        ............... day, .......................................................... 20..........




Dated ...................................... 20 .......         .......................................................
        Governor

(Reverse)

Certificate

I certify that the result of the election held under this writ was as follows:


Elected candidate(s)                 Date of declaration

.....................................                 ...................................
[continue as required]


Dated ...................................... 20 .......         .......................................................
        Electoral Commissioner

        [Form 23E inserted in Gazette 20 Oct 2000 p. 5946‑7.]

Form 23F

Western Australia

Electoral Act 1907 (s. 67(4))

Certificate of death of a member of the Legislative Assembly


To the Governor (or Speaker):


We, the undersigned, being 2 members of the Legislative Assembly, certify that .............................................................., a member of the Legislative Assembly serving for the ................................................. electoral district, died on the ..................................................... 20......, and we give you this notice to the intent that you may cause the writ to be issued for the election of a member to supply the vacancy caused by the death of that member.


Dated: .................................. 20........                 .............................................
                Member for the

.............................................
electoral district


.............................................

Member for the

.............................................
electoral district

        [Form 23F inserted in Gazette 20 Oct 2000 p. 5948.]

[Form 24 deleted in Gazette 10 Nov 2000 p. 6175.]

Form 25

Western Australia

Electoral Act 1907 (s. 87A(2))

RETURNING OFFICER’S RECEIPT FOR NOMINATION AND DEPOSIT

I acknowledge receipt of a deposit of $250 cash/bank or other financial institution cheque payable to the Electoral Commissioner* and a nomination paper in respect of ..................................................................................................
        (name of candidate)

...........................................................         ........................................................
        Date         Returning Officer

        ........................................................
        District or Region

* Strike out whichever is not applicable

        [Form 25 amended in Gazette 8 Nov 1996 p. 6269; 20 Nov 1998 p. 6265.]

Form 26

Western Australia

Electoral Act 1907 (s. 90)

APPLICATION FOR AN EARLY BALLOT PAPER


ELECTOR TO COMPLETE — PLEASE PRINT CLEARLY IN BLACK INK

SURNAME OR FAMILY NAME


GIVEN NAMES


ADDRESS AS ENROLLED OR FOR WHICH ENROLMENT IS CLAIMED






Postcode

PHONE
NUMBERS

Home

Work

DATE OF BIRTH

/ /


I am an elector for the


District





and am entitled to apply for an early ballot paper. I request that voting material be sent to me at:



Postcode

(If the same as your address as enrolled, print “As above”)



/ /

Signature or mark of applicant



Date



/ /

Signature of authorised witness
(only if applicant makes a mark)



Date



FOR ISSUING OFFICERS USE ONLY

DATE RECEIVED


NO.


SIGNATURE


PLACE OF ISSUE


        [Form 26 amended in Gazette 10 Nov 2000 p. 6177‑8.]

Form 27

Western Australia

Electoral Act 1907 (s. 90(7))

REJECTION OF WRITTEN APPLICATION FOR EARLY BALLOT PAPER


To ....................................................................................... :

I refer to your application for an early ballot paper for .........................................

.................................................................................................................................

(nature and date of election to be inserted)

Your application has been rejected for the following reasons:

.................................................................................................................................

.................................................................................................................................

.................................................................................................................................

.................................................................................................................................




.........................................................
ISSUING OFFICER

.........................................................
DATE

        [Form 27 inserted in Gazette 10 Nov 2000 p. 6178.]

Form 28

Western Australia

Electoral Act 1907  (s. 90(4)(c) and (4c)(b))

DECLARATION FOR EARLY VOTE

Electoral District of:

Please use BLOCK LETTERS when completing this form.

ELECTOR to complete.

Family name:                         Given name:

Address as enrolled:

Date of birth:                         Former family name:

To the Electoral Commissioner,

I declare that:

              •         I am the elector who applied for and was issued the enclosed ballot paper(s) for the election on Saturday ...../...../.....; and

              •         I live at, or within the previous 3 months have lived at, the above enrolled address; and

              •         I have not already voted at this election.

Elector to sign: ....................................

If you need assistance you may appoint a person, other than a candidate in this election, to fill in this form and mark the ballot paper(s). The person must complete the following section.

ASSISTANT to complete.

Family name:                         Given name:

Address:

I have been appointed by the elector to mark the enclosed ballot paper(s) and I have marked the ballot paper(s) in the way he/she has instructed.

Assistant to sign:                         Date:

AUTHORISED WITNESS to complete.

A witness must be more than 18 years of age and must not be a candidate in this election.

Family name:                         Given name:

Address:

Witness to sign:                                 Date:

        [Form 28 inserted in Gazette 11 May 2007 p. 1998.]

Form 29

Western Australia

Electoral Act 1907 (s. 92(6))

DECLARATION OF AN ELECTOR WHO HAS NOT RECEIVED AN EARLY BALLOT PAPER

I, ........................................................................................................................

(name in full)

of .......................................................................................................................

(address)

declare that I have not received an early ballot paper for which I applied for the election being held on ............................................................... and I now wish to vote personally at this polling place.


...................................................................
Signature of elector

Declared before me on ......................................................................................

(date)

at ....................................... polling place in the .................................. District.



..................................................................

                Signature of presiding officer

        [Form 29 inserted in Gazette 10 Nov 2000 p. 6180.]

[Form 30 deleted in Gazette 11 May 2007 p. 1998.]

Form 31

Western Australia

Electoral Act 1907  (s. 99A, 119(4), 122(1), 122A)

[r. 14(b)(i), 15(a)(i)]

DECLARATION FOR:

ABSENT VOTE;

PROVISIONAL VOTE.

Electoral District of:

Please use BLOCK LETTERS when completing this form.

ELECTOR to complete.

Family name:                         Given name:

Address as enrolled:

Date of birth:                         Former family name:

To the Electoral Commissioner,

I declare that:

              •         I live at, or within the previous 3 months have lived at, the above enrolled address; and

              •         I enrolled to vote before close of the roll for this election; and

              •         I have not already voted at this election.

Elector to sign: ....................................

Presiding Officer/Assistant Presiding Officer/Poll Clerk to complete.

Polling place at which vote claimed:

Presiding officer to sign:                 Date:

        [Form 31 inserted in Gazette 11 May 2007 p. 1999.]

Form 32

Western Australia

Electoral Act 1907 (s. 150)

STATISTICAL RETURN

.............................................(District (or Region))                                                              ...........................................(Date of election)

Total
Votes





I certify that this return is correct.

...................................................
Signature of Returning Officer

[This return may be made in a written or electronic form.]

...................................................
Date

[This return may be made in a written or electronic form.]

Ballot papers
rejected as
informal





Total Valid
Votes





Details of count of valid votes

Candidate





Candidate





Candidate





Candidate





Candidate





Polling
Places

Remote areas

Special
Institutions
and hospitals

Total:

Ordinary
Votes

Postal Votes

Absent Votes

Provisional
Votes

Total


Form 33

Western Australia

Electoral Act 1907  (s. 156(6))

APPARENT FAILURE TO VOTE — PENALTY NOTICE


[insert name and address of elector]


Dear elector

It appears from the Western Australian Electoral Commission’s records that you did not vote at the State election held on [insert election date] .

The Electoral Act 1907 section 156 requires every elector to vote at a State election unless the elector has a valid and sufficient reason for not voting.

If you did vote at the State election please tell us where or how you voted. Do this by completing Part A of Section 1 on the reverse of this notice.

If you did not vote at the State election and you believe you have a valid and sufficient reason for not voting, please tell us your reason. Do this by completing Part B of Section 1 on the reverse of this notice. If your reason is accepted, you will not need to pay a penalty. If your reason is not accepted, we will tell you and you will need to pay a penalty of [insert amount of penalty] .

If you did not vote at the State election and you do not have a valid and sufficient reason for not voting and you wish to finalise this matter, please pay the penalty of [insert amount of penalty] . Do this in one of the ways described in Section 2 on the reverse of this notice.

You must either complete and return this notice or pay the penalty before the following date. If you do not, this matter may be dealt with in court or referred to the Fines Enforcement Registry.

Due date for return of notice or payment of penalty: [insert date]

If you are away from home or physically incapacitated at the time this notice is delivered then you may direct another person to either complete and return this notice on your behalf or pay the penalty on your behalf.

This matter cannot be settled by telephone. However if you have any questions about how to deal with this notice please contact the Western Australian Electoral Commission by telephoning [insert telephone numbers] .

Thank you for your cooperation.

Electoral Commissioner                         Date: [insert date]

[Back of Form 33]

The address for which you are enrolled is: [insert address]

Please provide your current residential address if different from the above address:

SECTION 1

              •         Unless you choose to pay the penalty amount in one of the ways described in Section 2, complete this section and return this notice to the Western Australian Electoral Commission by posting it in the reply paid envelope provided or by delivering it to [insert address] .

              •         Complete either Part A or Part B but not both.

              •         Making a false or misleading statement on this notice is an offence.

Part A

If you did vote , complete this Part by ticking the appropriate box and completing the required details.


I voted:

□         by ordinary vote

□         by absent vote

□         by provisional vote

□         by early vote

at the following polling place*.....................................................

(*not applicable if early vote obtained by written application).

Part B

If you did not vote and you believe you have a valid and sufficient reason, complete this Part.


I did not vote because:

......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

The person completing Section 1 is to provide the following information about himself or herself:


Name: .........................................         Daytime contact phone number: ........................


Signature of person completing this form: ...............................................................

SECTION 2

Penalty: [insert penalty amount] Due date: [insert date]

If you did not vote and you wish to finalise this matter, please pay the penalty in one of the following ways by the due date.

Payment with Australia Post

[insert information about payment]





Payment by mail

Using the reply paid envelope provided, return this notice with a cheque or money order made payable to the Western Australian Electoral Commission. Do not send cash in the mail.

Payment in person

Cash or cheque payments can be made at the Western Australian Electoral Commission [insert address] .

Payment of the penalty will end this matter. However if you pay by cheque or credit card and that payment is dishonoured, you will be treated as if you had not paid the penalty.

        [Form 33 inserted in Gazette 11 May 2007 p. 1999‑2001.]

Form 34

Western Australia

Electoral Act 1907  (s. 156(12))

FAILURE TO VOTE — INFRINGEMENT NOTICE


[insert name and address of elector]


Dear elector

Thank you for returning the notice we sent you regarding your apparent failure to vote at the State election held on [insert date] .

In that notice you told us that

[insert whichever paragraph applies —

              •         you voted at [insert polling place]. The Western Australian Electoral Commission has used that information to re‑check its records but remains unable to find any record of you having voted.

              •         you voted by absent/provisional/early [insert whichever applies] vote. The Western Australian Electoral Commission has used that information to re‑check its records but remains unable to find any record of you having voted.

              •         you told us that you did not vote and you told us your reason for not doing so. The Electoral Commissioner has considered that reason but is unable to accept it as a valid and sufficient reason for not voting.]

The Electoral Commissioner therefore considers that you have committed an offence by failing to vote without a valid and sufficient reason. The penalty for this offence is [insert penalty amount] .

You must pay the penalty before the following date:

Due date for payment of penalty: [insert date]

If you do not pay the penalty before this date, this matter may be dealt with in court or referred to the Fines Enforcement Registry.

You may pay the penalty in one of the following ways:

Payment by mail

Using the reply paid envelope provided, return this notice with a cheque or money order made payable to the Western Australian Electoral Commission. Do not send cash in the mail.

Payment in person

Cash or cheque payments can be made at the Western Australian Electoral Commission [insert address] .

Payment of the penalty will end this matter. However if you pay by cheque and your cheque is dishonoured, you will be treated as if you had not paid the penalty.

Thank you for your cooperation.



Electoral Commissioner                                 Date: [insert date]

        [Form 34 inserted in Gazette 11 May 2007 p. 2001‑2.]

Form 35

Western Australia

Electoral Act 1907   (s. 156C(1)(a))

NOTIFICATION OF A VACANCY IN THE
LEGISLATIVE COUNCIL


Take notice that a vacancy in the Legislative Council has occurred for the seat in the..................................Region to which the Hon...............................had most recently been elected.

This notice is published under section 156C(1)(a) because —

1.         I have been informed of the vacancy by His/Her Excellency the Governor; and

2.         I am satisfied that it is practicable to fill the vacancy under sections 156C and 156D of the Electoral Act 1907 .

............................................................... .............................................................

Date         Electoral Commissioner

.................................................................
Address

        [Form 35 inserted in Gazette 6 Dec 1996 p. 6723.]

Form 36

Western Australia

Electoral Act 1907   (s. 156C(5))

NOMINATION TO FILL A VACANCY IN THE LEGISLATIVE COUNCIL UNDER SECTION 156C


To the Electoral Commissioner

I, the undersigned, being a qualified person as defined in section 156A of the Electoral Act 1907 , by this notice consent to act as a member of the Legislative Council in the...............................................Region referred to in your notice of.............................................................

Surname..................................................................................................................

Given names ..........................................................................................................

Residence ...............................................................................................................

Occupation .............................................................................................................

Form of name
printed on the ballot paper .....................................................................................

..........................................................   ..............................................................
Signature of witness who        Signature of Candidate
must be an elector

.....................................................................
Date

        [Form 36 inserted in Gazette 6 Dec 1996 p. 6724.]

Form 37

Western Australia

Electoral Act 1907   (s. 113(4)(a))


WATERMARK



        [Form 37 amended in Gazette 8 Nov 1996 p. 6277.]



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