Municipal Elections Act Forms
prescribed under subsection 167(1) of the
Municipal Elections Act
R.S.N.S. 1989, c. 300
O.I.C. 97-469 (July 15, 1997), N.S. Reg. 84/1997
amended to N.S. Reg. 176/2024 (effective August 15, 2024)
Table of Contents
Please note: this table of contents is provided for convenience of reference and does not form part of the regulations.
Click here to go to the text of the regulations.
Form 1: Oath or Affirmation of Returning Officer/AssistantReturning Officer/Revising
Officer
Form 2: Oath or Affirmation of Deputy Returning Officer/Poll Clerk
Form 3: Certificate in Respect to Charges that are Liens/Taxes
Form 4: Oath or Affirmation of Registrar of Voters
Form 5: Oath or Affirmation of Enumerator
Form 6: Index Sheet (Alphabetical)
Form 6A: Index Sheet (Geographic)
Form 7: Enumerator’s Certificate
Form 8: Oath or Affirmation of Elector Applying To Be Added to the List of Electors
Form 8A [repealed]
Form 8B [repealed]
Form 8C [repealed]
Form 9: Oath or Affirmation of Person Applying for Amendment of the List of Electors
Form 9A [repealed]
Form 10: Oath or Affirmation of Person Applying to Correct Errors on List of Electors
Form 10A [repealed]
Form 10B [repealed]
Form 11: Nomination Paper (Mayor or Other Council Member)
Form 11A [repealed]
Form 11B: Nomination Paper (Conseil scolaire acadien provincial)
Form 11C: [repealed]
Form 12: Affidavit re Removal of Advertising Materialsand Return of Lists of Electors
Form 12A: Declaration of Candidate Withdrawing from Nomination
Form 13: Ballot paper
Form 13A: Ballot Paper/Plebiscite
Form 14: Format of Poll Book
Form 14A: Format of Poll Book/Plebiscite
Form 15: Appointment of Agent (Polling Station)
Form 16: Oath or Affirmation of Agent Representing a Candidate (Polling Station)
Form 17: Appointment of Official Agent
Form 17A: Oath (or Affirmation) of Official Agent
Form 18: Declaration of Person Applying for a Transfer Certificate
Form 19: Transfer Certificate (Polling Station)
Form 20: Transfer Certificate (Polling District)
Form 21: Application for a Proxy Vote
Form 22: Number ____, Proxy Paper
Form 23: Directions to Electors
Form 23A [repealed]
Form 24: Elector’s Oath or Affirmation of Qualification at Poll
Form 24A [repealed]
Form 25: Oath or Affirmation of Elector Requiring Assistance
Form 26: Oath or Affirmation of Friend of Elector Requiring Assistance (Unrelated)
Form 26A: Oath or Affirmation of Friend of Elector RequiringAssistance
(Candidate/Relative)
Form 27: Oath or Affirmation of Interpreter
Form 28: Oath or Affirmation as to Error on List
Form 29: Oath or Affirmation of a Personated Elector
Form 30: Record of Poll
Form 30A: Record of Poll/Plebiscite
Form 31: Oath or Affirmation of Elector Not on List of Electors on Polling Day
Form 31A: [repealed]
Form 31B: Oath or Affirmation of Elector Not on List of Electors on Polling Day (Where
elector can vote only for Conseil scolaire acadien provincial)
Form 31C [repealed]
Form 31D [repealed]
Form 32: Affidavit of Proxy Voter
Form 33: Statement of Poll (One Candidate or Matter)
Form 34: Statement of Poll (More Than One Candidate or Matter)
Form 34A: Statement of Poll to be Completed when Conseil scolaire acadien
provincialBallots to be Transferred for Counting
Form 35: Tally Sheet For the Counting of Votes
Form 35A: Tally Sheet for the Counting of Votes/Plebiscite
Form 36: Tally Sheet for the Counting of Votes At a Plebiscite
Form 37: Persons Who Have Voted at the Advance Poll
Form 38: Recapitulation Sheet
Form 38A [repealed]
Form 39: Council Member’s Oath of Allegiance and of Office
Form 40: Candidate’s Campaign Contributions Disclosure Statement
Form 41: Association’s Campaign Contributions Disclosure Statement
Form 42 [repealed]
Form 43 [repealed]
Form 44: Statement of Poll, Consolidated Count of Conseil scolaire acadien provincial
Ballots(One Member to be Elected from the CSAP Electoral District)
Form 45: Statement of Poll, Consolidated Count of Conseil scolaire acadien provincial
Ballots(More than One Member to be Elected from the CSAP Electoral District)
Form 46: Record of Objections
Form 1: Oath or Affirmation of Returning Officer/Assistant
Returning Officer/Revising Officer
(Sections 4, 8, 33)
I, ____________ swear (or solemnly affirm) that I will act faithfully and impartially in the
performance of my duties as Returning Officer/Assistant Returning Officer/ Revising Officer in
the Town/Municipality/Regional Municipality of _____________.
Sworn (or affirmed) at
in the County of
this _____ day of ,
_______, before me
________________________ ____________________________________________
(see Section 146) Returning Officer/Assistant Returning Officer/Revising
Officer
________________________________________________________________
Form 2: Oath or Affirmation of Deputy Returning Officer/Poll Clerk
(Sections 8, 59)
I, _____________, swear (or solemnly affirm) that I will act faithfully and impartially in the
performance of my duties as _____________, that at the election to be held in the Town/
Municipality/Regional Municipality of _________ on the __ day of ______, __, I will not
attempt in any way unlawfully to ascertain the candidate or candidates for whom a voter has
voted, and will not in any way aid in the unlawful discovery of the same, and will keep secret
all knowledge which may come to me of the persons for whom any voter has voted.
I have not been convicted of a corrupt practice, as defined in the Municipal Elections Act, or of
bribery.
Sworn (or affirmed) at
in the County of
this _____ day of ,
_______, before me
__________________________ ______________________________
(see Section 146) Deputy Returning Officer/Poll Clerk
________________________________________________________________
Form 3: Certificate in Respect to Charges that are Liens/Taxes
(Sections 17, 44, 45)
I certify that as of the ______________ day of ____________________, ______, (nomination day)
___________________________________ (name of candidate) has fully paid all (i) the charges
that are liens on property that are due, (ii) all the municipal taxes that are due, and (iii) all
instalments or interim payments that are due as of nomination day have been paid to the
Town/Municipality/Regional Municipality of ______________________ from the candidate.
______________________________________
Clerk, Treasurer, Collector or other official
having knowledge of the facts
________________________________________________________________
Form 4: Oath or Affirmation of Registrar of Voters
(Section 22)
I, _____________________ swear (or solemnly affirm) that I will act faithfully and impartially
in the performance of my duties as registrar of voters in the Town/ Municipality/Regional
Municipality of ________________, will take all necessary precautions and care to ensure the
accuracy of the enumeration, and will protect the confidentiality of elector information.
Sworn (or affirmed) at
in the County of
this _____ day of ,
_______, before me
_________________________ ___________________________________
(see Section 146) Registrar of Voters
________________________________________________________________
Form 5: Oath or Affirmation of Enumerator
(Section 23)
I, ________________________________ (name in full) of ____________________, (residence)
appointed enumerator for the Town/Municipality/Regional Municipality of ____________
swear (or solemnly affirm) that I will act faithfully in my capacity as enumerator without
partiality and will take all necessary precautions and care to ensure that the enumerators’ index
sheet contains correct information concerning all qualified electors in Polling Division Number
_____ and will not contain the names of any persons who are not qualified. I will protect the
confidentiality of elector information that is provided to me.
Sworn (or affirmed) at
in the County of
this _____ day of ,
_______, before me
________________________ ____________________________________
(see Section 146) Enumerator
________________________________________________________________
Form 6: Index Sheet (Alphabetical)
(Section 25)
*Polling Division (Number, Name or Description) __________________________________
Consecutive
Number
(Optional)
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Name
(surname, first name
and middle name or
initial)
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Address
Civic Address (number,
street, community)
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Mailing Address
(if different than civic–
include postal code)
(if necessary)
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Date of birth
(to be removed
from final list of
electors)
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* Returning Officer to indicate how poll is to be identified
________________________________________________________________
Form 6A: Index Sheet (Geographic)
(Section 25)
*Polling Division (Number, Name or Description)
Consecutive
Number
(Optional)
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Civic
Number
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Name
(surname, given name and
middle name or initial)
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Mailing Address
(if different from
civic–include postal
code) (if necessary)
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Date of birth
(to be removed from
final list of electors)
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(Name of street/avenue/road/highway and community):
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(Name of street/avenue/road/highway and community):
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* Returning Officer to indicate how the poll is to be identified
________________________________________________________________
Form 7: Enumerator’s Certificate
(Section 27)
I/We, the undersigned enumerator(s), certify that I/we have taken all necessary precautions and
care to ensure that the index sheets attached contain correct information concerning the
qualified electors in Polling Division Number ________ and do not contain the names of any
persons who are not so qualified.
Dated this ______ day of _____________, ______
_______________________________
_______________________________
Enumerator(s)
________________________________________________________________
Form 8: Oath or Affirmation of Elector Applying To
Be Added to the List of Electors
(Section 36, 38, 50A)
I swear (or solemnly affirm) that:
1. On this date, I actually reside in Polling Division Number ____________ of Polling
District Number _____________ of the Town/Municipality/Regional Municipality of
___________________________________________________ (the “Municipality”).
2. As of the first polling day in this election, I will have been ordinarily resident in:
•the Province of Nova Scotia for a period of six (6) months; and
•the Municipality (or in an area annexed to the Municipality).
3. As of the first advance polling day in this election, I will have been or will be a Canadian
citizen and of the full age of eighteen years or more.
4. I am not the returning officer, a person serving a sentence in a penal or reform institution,
or a person convicted of bribery under the Municipal Elections Act in the six years
preceding ordinary polling day.
5. I wish to be added to the list of electors for the purpose of voting in this election.
Name of Elector
(please print)
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Civic Address of Elector
(and mailing address, if necessary)
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Date of Birth
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Sworn (or affirmed) at _____________________
in the _____________ of ___________________
this _______ day of ________________
_________, before me
______________________________ ____________________________
Revising Officer Applicant
The Voters List may be used in future municipal, provincial or federal elections.
(Date of birth will be removed from the final list of electors.)
________________________________________________________________
Form 8A [repealed]
Form 8B [repealed]
Form 8C [repealed]
________________________________________________________________
Form 9: Oath or Affirmation of Person Applying for
Amendment of the List of Electors
(Section 35, 36)
I ____________________________ of __________________________, swear (or solemnly
(name) (address)
affirm) that I believe that ______________________ of______________________________,
(name) (address)
registered on the list of electors for Polling Station Number ________ in Polling District
Number ________, in the Town/Municipality/Regional Municipality of
________________________(the “Municipality”) should not be on the list because (place a
check mark next to the applicable statement)
_______ the person does not reside at the address shown;
_______ the person is not the full age of eighteen years and will not be as of the first
advance polling day;
_______ the person is not a Canadian citizen or will not be as of the first advance
polling day;
_______ the person has not been or will not have been ordinarily resident in:
• the province of Nova Scotia for six (6) months; and
• the Municipality.
as of the first advance polling day in this election;
_______ the person is dead.
Sworn (or affirmed) at ____________________
in the _____________ of _________________________
this _______ day of ______________________,
_________, before me
_________________________________ _______________________________
Revising Officer Applicant
________________________________________________________________
Form 9A [repealed]
________________________________________________________________
Form 10: Oath or Affirmation of Person Applying to
Correct Errors on List of Electors
(Subsection 37(2))
I _____________________, (name of elector/agent of elector) of _______________________, (address)
swear (or solemnly affirm) that _____________________, (name of elector) whose address is given
as ____________________________, (address as on official list of voters) appears with an error
(errors) on the preliminary list of electors, and should be shown on the list as
____________________________ ______________________________
(name) (address)
Sworn (or affirmed) at
in the County of
this _____ day of ,
_______, before me
_____________________________ ______________________________
Revising Officer Applicant
________________________________________________________________
Form 10A [repealed]
Form 10B [repealed]
________________________________________________________________
Form 11: Nomination Paper (Mayor or Other Council Member)
(Section 44)
We, the qualified electors whose names appear on the amended list of electors of the
Town/Municipality/Regional Municipality of ______________________________________ ,
nominate__________________________________________________________________ of
(name)
____________________________________________________________________________,
(civic address)
_____________________________________ _______________________________
(postal code)
____________________________________________________________________________
(include mailing address if different than civic address )
as a candidate for the office of _______________________________ for the election to be held
on the _______________ day of ______________________________, __________________.
Name (please print) Civic Address Signature
_____________________ _______________________ _______________________
_____________________ _______________________ _______________________
_____________________ _______________________ _______________________
_____________________ _______________________ _______________________
_____________________ _______________________ _______________________
_____________________ _______________________ _______________________
_____________________ _______________________ _______________________
_____________________ _______________________ _______________________
Note:
1. These electors must be qualified to vote at the election of the candidate. At least 5
qualified electors must sign the nomination form.
2. Nomination forms are open for inspection by the public once signed by the
Returning Officer.
Consent and Oath or Affirmation of Candidate
I solemnly swear (or affirm) that:
1. I (The candidate), _________________________________, consent(s) to the nomination.
(name as it should appear on the ballot paper)
2. I am (The candidate is) a Canadian citizen.
3. I am (The candidate is) of the full age of eighteen years.
4. I have (The candidate has) been ordinarily a resident in the Town/Municipality/Regional
Municipality of ____________________________________________, (or in an area
annexed to the Town/Municipality/Regional Municipality), for a period of six months
preceding nomination day and I intend (the candidate intends) to continue to so reside.
5. I am (The candidate is) not indebted to the Town/Municipality/Regional Municipality of
___________________________ for any charges that are liens on property or taxes, or all
instalments or interim payments that are due as of nomination day have been paid, and a
certificate from the __________________________________ to this effect is attached.
6. I have (The candidate has) not been convicted of bribery or of committing a corrupt
practice under the Municipal Elections Act within the five years preceding nomination day.
7. I have (The candidate has) read the Sections of the Municipal Elections Act related to
persons disqualified to vote, to be nominated or to serve on a council and none of the
reasons for disqualification listed in those Sections apply to me (the candidate).
8. I have (The candidate has) read and I understand (the candidate understands) the
provisions of the Municipal Elections Act related to the requirement to take a leave of
absence if I am (the candidate is) an employee of the Town/Municipality/Regional
Municipality within the meaning of those provisions.
9. I understand (the candidate understands) that a list of electors is permitted to be used for
election purposes and for no other purposes and that it is not to be open for inspection,
disposed of or sold.
10. I understand (the candidate understands) that, within 7 days following the election, all
copies of the list of electors in my (the candidate’s) possession must be returned and all
electronic copies must be returned, destroyed or deleted. I further understand (The
candidate understands) that if I fail (the candidate fails) to do so, I forfeit (the candidate
forfeits) any candidate’s deposit to which I (the candidate) might otherwise be entitled to
receive.
11. I (The candidate) will accept the office of _________________________________ if
elected.
12. I appoint (The candidate appoints) _______________________________________ of
_____________________ as my (the candidate’s) official agent under the Municipal
Elections Act.
Sworn (or affirmed) at _________________________
in the County of ______________________________
this ___________ day of _______________________
_______________, before me
_________________________________ _______________________________
Authorized Administrator of Oath Candidate (or Agent if authorized
(See Section 146) and the authorization is attached)
Receipt
Received from the above-named candidate or from the candidate’s agent on the candidate’s
behalf a completed nomination paper and the sum of _____________ in legal tender or a
certified cheque or money order made payable to the Town/Municipality/Regional Municipality
of __________________________ as a deposit pursuant to the Municipal Elections Act.
Dated at ________________________ this__________ day of ___________________, _____.
_______________________________
Returning Officer
________________________________________________________________
Form 11A [repealed]
________________________________________________________________
Form 11B: Nomination Paper (Conseil scolaire acadien provincial)
(Section 44)
(Section 18, Conseil scolaire acadien provincial Act)
District__________________________________________
(name)
We, the qualified electors whose names appear on the amended list of electors for the
municipality shown opposite each name, nominate: _________________________________ of
(name)
____________________________________________________________________________,
(civic address)
_________________________________________ _______________________________
(postal code)
____________________________________________________________________________
(include mailing address if different than civic address)
as a candidate for the office of ____________________________ for the election to be held on
the ____________ day of __________________________________, __________________.
(Note: Nominators to sign below and also to sign “Statement of Nominators”.)
Name (please print) Civic Address Municipality
______________________ _________________________________________________
______________________
Signature
Name (please print) Civic Address Municipality
______________________ _________________________________________________
______________________
Signature
Name (please print) Civic Address Municipality
______________________ _________________________________________________
______________________
Signature
Name (please print) Civic Address Municipality
______________________ _________________________________________________
______________________
Signature
Name (please print) Civic Address Municipality
______________________ _________________________________________________
______________________
Signature
Note:
1. These electors must be qualified to vote at the election of the CSAP candidate.
2. Nomination forms are open for inspection by the public once signed by the
Returning Officer.
Statement of Nominators
Under the Conseil scolaire acadien provincial Act, only an “entitled person” may nominate a
candidate for election as a member of the Conseil scolaire acadien provincial. “Entitled person”
is defined to mean an entitled parent or a person who, not being an entitled parent, would be an
entitled parent if the person were a parent.
Under the Conseil scolaire acadien provincial Act, an “entitled parent” is defined to mean a
parent who is a Canadian citizen AND
(a) whose first language learned and still understood is French; OR
(b) who received primary school instruction in Canada in a French-first-language
education program; OR
(c) of whom any child has received or is receiving primary or secondary school
instruction in Canada in a French-first-language education program (note that the
definition of “parent” does not include a guardian or person acting in loco parentis to
a child).
I state that I am an “entitled person” within the meaning of this definition.
___________________________________ _______________________________
Name (please print) Signature
___________________________________ _______________________________
Name (please print) Signature
___________________________________ _______________________________
Name (please print) Signature
___________________________________ _______________________________
Name (please print) Signature
___________________________________ _______________________________
Name (please print) Signature
Statement of Candidate
Under the Conseil scolaire acadien provincial Act, only an “entitled person” may be a member
of the Conseil scolaire acadien provincial. “Entitled person” is defined to mean an entitled
parent or a person who, not being an entitled parent, would be an entitled parent if the person
were a parent.
Under the Conseil scolaire acadien provincial Act, an “entitled parent” is defined to mean a
parent who is a Canadian citizen AND
(a) whose first language learned and still understood is French; OR
(b) who received primary school instruction in Canada in a French-first-language
education program; OR
(c) of whom any child has received or is receiving primary or secondary school
instruction in Canada in a French-first-language education program (note that the
definition of “parent” does not include a guardian or person acting in loco parentis to
a child).
I state that I am an “entitled person” within the meaning of this definition.
____________________________________
Candidate
(Note: This Statement must be signed by the candidate; it cannot be signed by the official
agent.)
Consent and Oath or Affirmation of Candidate
I swear (or solemnly affirm) that:
1. I (The candidate), __________________________________________, consent(s) to the
(name as it should appear on the ballot paper)
nomination.
2. I am (The candidate is) a Canadian citizen.
3. I am (The candidate is) of the full age of eighteen years.
4. I have (The candidate has) been ordinarily resident in the electoral district for a period of
six months preceding nomination day or the day of appointment, and continue(s) to so
reside.
5. I have (The candidate has) not been convicted of any corrupt practice or bribery under the
Municipal Elections Act within the ten years preceding nomination day.
6. I have (The candidate has) read and I understand (the candidate understands) all the
provisions of the Conseil scolaire acadien provincial Act related to the disqualifications of
a person from being nominated or to serve as a member of the Conseil scolaire acadien
provincial and none of those reasons for disqualification apply to me (the candidate).
7. I understand (The candidate understands) that a list of electors is permitted to be used for
election purposes and for no other purposes and that it is not to be open for inspection,
disposed of or sold.
8. I understand (The candidate understands) that, within 7 days following the election, all
copies of the list of electors in my (the candidate’s) possession must be returned and all
electronic copies must be returned, destroyed or deleted. I further understand (The
candidate understands) that if I fail (the candidate fails) to do so, I forfeit (the candidate
forfeits) any candidate’s deposit to which I (the candidate) might otherwise be entitled to
receive.
9. I (The candidate) will accept the office of the member of the Conseil scolaire acadien
provincial if elected.
10. I (The candidate) appoint(s) _____________________ of __________________________
(name) (address)
as my (the candidate’s) official agent under the Municipal Elections Act.
Sworn (or affirmed) at _________________________
in the County of ______________________________
this ___________ day of _______________________
_______________, before me
___________________________________ _______________________________
Authorized Administrator of Oath Candidate (or Agent if authorized
(See Section 146) and the authorization is attached)
Receipt
Received from the above-named candidate or from the candidate’s agent on the candidate’s
behalf a completed nomination paper and the sum of __________________________ in legal
tender or a certified cheque or money order made payable to the Town/Municipality/Regional
Municipality of _____________________________ as a deposit pursuant to the Municipal
Elections Act.
Dated at ______________________ this__________ day of _____________________, _____.
_______________________________
Returning Officer
(A translation of this form is available in French.)
________________________________________________________________
Form 11C: [repealed]
________________________________________________________________
Form 12: Affidavit re Removal of Advertising Materials
and Return of Lists of Electors
(Section 51)
I, ___________________________________, (name of candidate) solemnly swear (or affirm) that:
1. I was a candidate for the office of _______________________ of the ________________
at the election held on the ______ day of _______________, ____.
2. I have removed or caused to be removed all advertising and election materials which were
posted or displayed on my behalf.
3. I recognize that failure to remove advertising and election materials from public places is a
violation of the Municipal Elections Act.
4. I have returned all copies of the list of electors in my possession, and I have either
returned, destroyed or deleted any electronic copies provided to me or made by me.
Sworn (or affirmed) at __________________
in the County of _______________________
this ________ day of ____________________,
______, before me
_____________________ ______________________________________
(see Section 146) Candidate (or Official Agent if authorized and
the authorization is attached)
(TO BE FILED WITHIN 7 DAYS AFTER ELECTION DAY)
________________________________________________________________
Form 12A: Declaration of Candidate Withdrawing from Nomination
(Section 53)
To: Returning Officer,
Town/Municipality/Regional Municipality of _________________________________
I, _______________________________, (candidate’s name) officially nominated as a candidate at
the election now pending, withdraw as a candidate.
Dated at __________________________,
this _______ day of _______________.
______________________________________
Candidate/Official agent on behalf of candidate
________________________________________________________________
Form 13: Ballot paper
(Section 66)
FRONT
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Counterfoil
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Election for...................
Vote for not more than.........
candidate(s)
James Allen BROWN ◯
Frederika COOPER ◯
Ross George FINDLAY ◯
Jean Paul SURETTE ◯
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BACK
Stub
Counterfoil
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No. 000000
...................................
No. 000000
...................................
_________________
D.R.O. Initials
_______ of _______
Election for _______
_________________
Polling District (or
Ward) No. _____
_________, _______
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line of perforation
line of perforation
name of municipality
name of office for
councillors or school
board members
elected by ward or
polling district only
date of ordinary
polling day
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________________________________________________________________
Form 13A: Ballot Paper/Plebiscite
(Section 66)
FRONT
Stub
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Counterfoil
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DO YOU FAVOUR . . . . . . . . . .? YES ◯
NO ◯
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No. 000000. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
No. 000000
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
____________________
D.R.O. Initials
__________of_________
Plebiscite respecting _________
__________________________
_______________, __________
BACK
Stub
line of perforation
line of perforation
Counterfoil
name of municipality
description of question
date of ordinary
polling day
________________________________________________________________
Form 14: Format of Poll Book
(Section 68)
1. The cover of the poll book shall bear the subject of the election, the polling district
number, and the date of ordinary polling day.
2. The first page of the poll book shall contain Form 2.
3. The second page of the poll book shall contain Form 16.
4. Form 24 shall be on the third page, then Forms 25, 26, 26A, 27, 28, and 29 shall follow.
5. Then shall follow twelve pages of Form 30.
6. Then shall follow three pages of Form 31.
7. Then shall follow two pages of Form 31B.
8. Then shall follow three pages of Form 32.
9. Then shall follow eight pages of Form 33 or 34 for each matter for which a poll was
granted.
10. Then shall follow one page of Form 34A for each CSAP office to be elected.
11. Then shall follow eight pages of Form 35 for each matter for which a poll was granted.
12. Then shall follow two pages of Form 46, and the back cover.
This format may be varied by altering the number of copies of forms required to be included to
suit the circumstances of the election. Additional or loose copies of some forms also may be
used; these should be added to the poll book at the end of voting.
________________________________________________________________
Form 14A: Format of Poll Book/Plebiscite
(Section 68)
1. The cover of the poll book shall bear the subject of the election, the polling district
number, and the date of ordinary polling day.
2. The first page of the poll book shall contain Form 2.
3. Form 24 shall be on the second page, then Forms 25, 26, 26A, 27, 28, and 29 shall follow.
4. Then shall follow twelve pages of Form 30A.
5. Then shall follow three pages of Form 31.
6. Then shall follow three pages of Form 32.
7. Then shall follow eight pages of Form 33.
8. Then shall follow eight pages of Form 35A.
9 Then the back cover.
This format may be varied by altering the number of copies of forms required to be included to
suit the circumstances of the election. Additional or loose copies of some forms also may be
used; these should be added to the poll book at the end of voting.
________________________________________________________________
Form 15: Appointment of Agent (Polling Station)
(Section 71)
I, the undersigned, candidate (or the official agent of ____________________, (candidate’s name) a
candidate) for__________________________, (office) appoint the following as my (the
candidate’s) agent with authority to represent me (the candidate) in the manner provided by the
Municipal Elections Act at Polling Station Number ________ for the election being held on
_______________, _____.
______________________________ ___________________________________
(name of agent) (address of agent)
Dated at _____________ Nova Scotia, this ______ day of _____________, ____.
_______________________________________
Signature of candidate or of official agent
________________________________________________________________
Form 16: Oath or Affirmation of Agent Representing a Candidate (Polling Station)
(Section 69)
I ______________________ the undersigned, swear (or solemnly affirm) that, at the election to
be held in the Town/Municipality/Regional Municipality of __________ on the _____ day of
___________, _____, I will not attempt, in any way, unlawfully to ascertain the candidate or
candidates for whom a voter has voted and will not in any way aid in the unlawful discovery of
the same, and that I will keep secret all knowledge which may come to me of the persons for
whom any voter has voted.
Candidate’s Name
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Agent’s Signature
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Sworn (or affirmed) at_____________________
in the County of ____________ this ______ day of
________________, ___________, before me
________________________________
Deputy Returning Officer
________________________________________________________________
Form 17: Appointment of Official Agent
(Section 70)
I, the undersigned, a candidate for the office of _____________________________,
(place a check mark next to the applicable statement)
_____ appoint _________________ (name) of ___________________ (address) as my official
agent with authority to represent me in the manner provided by the Municipal
Elections Act at the election being held on _________________________, _______.
OR
_____ declare that I will act personally as official agent in the manner provided by the
Municipal Elections Act at the election being held on ________________, _______.
________________________
Signature of candidate
(A translation of this form is available in French.)
________________________________________________________________
Form 17A: Oath (or Affirmation) of Official Agent
(Section 70 )
I, _____________________________________________, the undersigned, swear (or solemnly
affirm) that as the official agent for ________________________________, a candidate in the
election to be held in the Town/Municipality/Regional Municipality of ____________________
on the __________ day of _______________________, __________, I will not attempt, in any
way, unlawfully to ascertain the candidate or candidates for whom a voter has voted or to aid in
the unlawful discovery of the same, and I will keep secret all knowledge which may come to
me of the persons for whom any voter has voted.
Sworn (or affirmed) at _________________
in the County of ______________________ _______________________________
this _____day of ________________, (Signature of Official Agent)
before me.
___________________________________
Commissioner or other Authorized Official
Municipal Elections Act, subsection [clause] 146(1)(b)
____________________________________
Print name and title
(A translation of this form is available in French.)
________________________________________________________________
Form 18: Declaration of Person Applying for a Transfer Certificate
(Section 73)
(This form [is] to be submitted to the Returning Officer before 5:00 p.m. on the
Wednesday before ordinary polling day.)
1. I am the elector whose name appears as follows in the list of electors for Polling Station
Number _________ in Polling District Number ___________ in the Town/Municipality/
Regional Municipality of _________________________________.
__________________________________________________
Number on List Name
_________________________________
Address
2. During the election I will not vote at the polling station where my name appears on the list
of electors unless I surrender the transfer certificate issued to me to the deputy returning
officer of that polling station.
3. I have not voted at the advance poll.
I request a transfer certificate to be issued to me to permit me to vote at Polling Station Number
_________ in Polling District Number _________ instead of the above polling station, because:
(place a check mark next to the applicable statement)
_____ I am a candidate, or
_____ I am an agent of a candidate who has appointed me to act at Polling Station
Number ________, where I intend to vote on election day, or
_____ I am a deputy returning officer or poll clerk who has been appointed to act at a
polling station other than where my name appears on the list of electors, or
_____ I am an assistant returning officer whose name appears on the list of electors for
a polling station other than where the headquarters of the returning officer are
situate, or
_____ I am prevented from voting at the above polling station because of physical
disability.
_________________________________
Applicant
________________________________________________________________
Form 19: Transfer Certificate (Polling Station)
(Section 73)
I certify that the elector named below is entitled under Section 73 of the Municipal Elections Act
to a transfer certificate permitting the elector to transfer their vote from Polling Station Number
__________ to Polling Station Number ___________ and I grant this certificate so authorizing
the elector.
_______________________________ _____________________________________
Name of Elector Address
Dated this ______ day of ________________, _____.
______________________________
Returning Officer or Assistant Returning Officer
Note: Complete in triplicate.
________________________________________________________________
Form 20: Transfer Certificate (Polling District)
(Section 73)
I certify that the elector named below is entitled under Section 73 of the Municipal Elections Act
to a transfer certificate permitting the elector to transfer their vote from Polling Station Number
_______ in Polling District Number __________ to Polling Station Number __________ in
Polling District Number ____________, and I grant this certificate so authorizing the elector to
vote for the election of ___________________________________ (specify mayor, councillor(s), CSAP,
plebiscite).
_______________________________ _____________________________________
Name of Elector Address
Dated this _____ day of _____________, ______.
_______________________________________
Returning Officer or Assistant Returning Officer
Note: Complete in triplicate.
________________________________________________________________
Form 21: Application for a Proxy Vote
(Section 76)
(This form is to be submitted to the Returning Officer before 5:00 p.m. on Friday, the eighth day
before ordinary polling day.)
Part 1
(to be completed by elector)
I declare that:
1. I am number _________ on the list of electors for Polling Division Number _______ in
Polling District Number ________ of the Town/Municipality/Regional Municipality of
_____________________________ (the “Municipality”).
2. I am applying to vote by proxy because
(Place a check mark next to the applicable statement)
_______ I will be absent from the Municipality on the advance poll days and on ordinary
polling day.
OR
_______ I cannot attend at the polling station because of illness or physical disability.
3. I appoint as my proxy voter _____________________________________________ who is
(state full name)
(Place check mark next to the applicable statement)
_______ an elector and whose number on the list of electors is _______for the
Town/Municipality/ Regional Municipality of _______________________.
OR
_______ related to me as __________________________________________________
(state relationship: child/grandchild/brother/sister/parent/grandparent[/]husband/wife)
and who is an elector on the list of electors of, the Town/Municipality/Regional
Municipality of _________________________________.
OR
(ONLY for residents of homes for the aged approved or nursing homes licensed under the
Homes for Special Care Act)
_______ related to me as __________________________________________________
(state relationship: child/grandchild/brother/sister/parent/grandparent[/]husband/wife)
and who is eighteen years of age or will as of the first advance polling day.
I declare that the above statements have been read by me or read to me and are true.
I also understand that I cannot vote in person on ordinary polling day unless I cancel the proxy
paper before five o’clock on the afternoon of Friday, the eighth day before ordinary polling day.
Dated at _____________________, this _______ day of ___________________, ________.
________________________________
Signature of the Elector
Part 2
Certificate of Proxy Voter
(to be completed by the proxy voter)
I, _________________________________________________________________, certify that:
(print name of proxy voter)
1. To the best of my knowledge, information and belief, all the information contained on the
above appointment of proxy voter is correct; and
2. (Place a check mark next to the applicable statement)
_____ I have not previously been appointed as proxy voter for any other elector during
the pending election.
OR
_____ I have previously been appointed as proxy voter only for one other elector
during the pending election, who is not related to me, and I am related to the
elector to whom this appointment relates as ____________________________.
(state relationship: child/grandchild/brother/sister/parent/grandparent[/]husband/wife)
OR
_____ I have previously been appointed as proxy voter during the pending election
only for:
______________________________________________________
______________________________________________________
(name and full address)
who is/are related to me as follows:
________________________________________________________________
(state relationship: child/grandchild/brother/sister/parent/grandparent[/]husband/wife)
3. I am
(Place a check mark next to the applicable statement)
_____ an elector on the list of electors for the same municipality as the elector for
whom I have been appointed as proxy voter.
OR
(ONLY for proxy voters for residents of homes for aged approved or nursing homes
licensed under the Homes for Special Care Act)
_____ related to the elector for whom I have been appointed as proxy voter as
________________________________________________________________
(state relationship: child/grandchild/brother/sister/parent/grandparent/husband/wife)
and I am or will be eighteen years of age as of the first advance polling day.
Dated at _____________________, this _______ day of _______________________, _______.
______________________________
Signature of Proxy Voter
PLEASE READ THE FOLLOWING IMPORTANT NOTICES:
1. A person may act as proxy voter for one unrelated elector and any number of electors who
are a child, grandchild, brother, sister, parent, grandparent, husband or wife of the proxy
voter.
2. This form must be presented to the Returning Officer by the elector or proposed proxy
voter in person before five o’clock on the afternoon of Friday the eighth day before
ordinary polling day so that a Proxy Paper in Form 22 may be issued.
3. APPOINTING A PROXY VOTER MEANS THAT THE ELECTOR CANNOT
VOTE OTHER THAN BY PROXY. THIS APPLICATION FORM DOES NOT
PERMIT AN ELECTOR TO VOTE ON ELECTION DAY.
________________________________________________________________
Form 22: Number ____, Proxy Paper
(Section 76)
(NOTE: A Proxy Voter can vote only on Ordinary Polling Day.
A Proxy Voter cannot vote at any Advance Poll)
TO: The Deputy Returning Officer
Polling Station Number ________________
Polling District of _________________
I certify that:
_________________________________________________________________________
(name of elector)
of_______________________________________________________________________
(address of elector)
being number __________ on the list of electors for the above polling station may vote by
proxy by the elector’s proxy voter,
_________________________________________________________________________
(name of proxy voter)
of_______________________________________________________________________
(address of proxy voter)
Dated at _________________ this ______ day of ___________________________, _______.
______________________________
Returning Officer
________________________________________________________________
Form 23: Directions to Electors
(Section 68)
Attention Electors
Mark the ballot paper by placing a cross, an “X”, a check mark, or a line made with a pencil or
pen in the circular space on the ballot paper at the right of the name of the candidate (or names
of the candidates if more than one are to be elected) for whom you intend to vote.
Election for Councillor
Vote for no more than the number of
candidates to be elected as the case may be.
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Examples:Vote for one candidate; or
Vote for no more than two candidates; or
Vote for no more than three candidates
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John James JONES
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Robert Simon SMITH
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Sheila Elaine TURNER
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Then fold and return to the Deputy Returning Officer.
A spoiled ballot may be exchanged for a new one.
WARNING: It is an offence to mark the ballot paper so that you may be identified.
________________________________________________________________
Form 23A [repealed]
________________________________________________________________
Form 24: Elector’s Oath or Affirmation of Qualification at Poll
(Section 83)
I swear (or solemnly affirm) that:
1. I am the person named (or intended to be named) _________________________________
in the list of electors now shown to me (being shown the list to the elector) and that on this
date of the poll in this election, I do actually reside in Polling Division Number _________
of the Town/Municipality/Regional Municipality of _______________________________
(the “Municipality”) and that the address of my residence is ________________________.
2. I am the full age of eighteen (18) years.
3. I am a Canadian citizen.
4. As of the first advance polling day, I have been ordinarily resident in
• the Province of Nova Scotia for a period of six (6) months; and
• in the Municipality.
5. I am not the returning officer, a person serving a sentence in a penal or reform institution,
or a person convicted of bribery under the Municipal Elections Act in the six (6) years
preceding ordinary polling day.
6. I have not voted before in this election at any polling place and will not do so or attempt to
do so and I have not received anything nor has anything been promised to me directly or
indirectly in order to induce me to vote or refrain from voting in this election.
Sworn (or affirmed) at ____________________
in the _________________________________
this ________ day of ___________________,
_________________, before me
___________________________________ ______________________________
Revising Officer Elector
________________________________________________________________
Form 24A [repealed]
________________________________________________________________
Form 25: Oath or Affirmation of Elector Requiring Assistance
(Section 86)
You swear (or solemnly affirm) that you require assistance in voting because you are blind,
unable to read or have a physical disability which prevents you from voting without assistance.
________________________________________________________________
Form 26: Oath or Affirmation of Friend of Elector Requiring Assistance (Unrelated)
(Section 86)
(For use by a person who is not a candidate and who is not related to the elector)
You swear (or solemnly affirm) that you have not previously acted as a friend for any other
elector in the election who is not a child, grandchild, brother, sister, parent, grandparent, husband
or wife, that you will carry out the wishes of the elector on whose behalf you act and that you
will keep secret the name of the candidate or candidates for whom you mark the ballot paper.
Note: A candidate may not act as friend of an elector who is not a child, grandchild,
brother, sister, parent, grandparent, husband or wife of the candidate. A person who is
not a candidate may act as friend for one unrelated elector and any number of electors
who are a child, grandchild, brother, sister, parent, grandparent, husband or wife of the
friend.
________________________________________________________________
Form 26A: Oath or Affirmation of Friend of Elector Requiring
Assistance (Candidate/Relative)
(Section 86)
(For use by a person, including a candidate, who is related to the elector)
You swear (or solemnly affirm) that the elector on whose behalf you act is a child, grandchild,
brother, sister, parent, grandparent, husband or wife, that you will carry out the wishes of the
elector and that you will keep secret the name of the candidate or candidates for whom you mark
the ballot paper.
Note: A candidate may not act as friend of an elector who is not a child, grandchild,
brother, sister, parent, grandparent, husband or wife of the candidate. A person who is
not a candidate may act as friend for one unrelated elector and any number of electors
who are a child, grandchild, brother, sister, parent, grandparent, husband or wife of the
friend.
________________________________________________________________
Form 27: Oath or Affirmation of Interpreter
(Section 87)
You swear (or solemnly affirm) that you shall well and truly interpret the questions asked of the
elector and explanations given to the elector, and the answers and questions of the elector, and
that you will keep secret any information so obtained.
________________________________________________________________
Form 28: Oath or Affirmation as to Error on List
(Section 92)
You swear (or solemnly affirm) that you believe that you are the person intended to be referred
to under the name (name as on official list of electors) whose address is given as (address as on
the official list of electors).
________________________________________________________________
Form 29: Oath or Affirmation of a Personated Elector
(Section 93)
You swear (or solemnly affirm) that you are (name as on official list of electors) of (address as
on official list of electors) whose name is entered on the list of electors now shown you, and that
you have not previously voted at this election.
Form 30: Record of Poll
(Section 94)
Order of
Voting
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No. on List of
Electors/
Certificate of
Eligibility
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Name of
Elector (Family
Name First)
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Address
of Elector
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Voted
for Mayor
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Voted for
Councillor
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Voted for
CSAP
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Voted
for Other
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Sworn or
Affirmed
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Refused
to Swear
or Affirm
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Transfer
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Added
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By
Proxy
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Remarks (e.g.,
form of oath
taken)
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Use a Check Mark
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________________________________________________________________
Form 30A: Record of Poll/Plebiscite
Consecutive
No.
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No. on
Voters’
List
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NAME OF ELECTORS
(FAMILY NAME FIRST)
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ADDRESS
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Voted
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Sworn or
Affirmed
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Refused to
Swear or
Affirm
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Transfer
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By
Proxy
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REMARKS
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Note: Electors who are added at the poll do not have a number on the list of electors.
________________________________________________________________
Form 31: Oath or Affirmation of Elector Not on List of Electors on Polling Day
(Section 98)
I swear (or solemnly affirm) that:
1. On this date, I actually reside in Polling Division Number __________ of Polling District
Number _____ of the Town/Municipality/Regional Municipality of __________________
(the “Municipality”).
2. As of the first advance polling day in this election, I have been ordinarily resident in:
• the Province of Nova Scotia for a period of six (6) months; and
• the Municipality (or in an area annexed to the Municipality).
3. I have not previously voted in this election at any other polling place, and I will not (or will
not attempt to) vote at any other polling place.
4. As of the first advance polling day, I was a Canadian citizen and of the full age of eighteen
years.
5. I am not the returning officer, a person serving a sentence in a penal or reform institution, or
a person convicted of bribery under the Municipal Elections Act in the six years preceding
ordinary polling day.
Name of Elector
(please print)
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Civic Address of Elector
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Date of Birth
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_______________________
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_______________________________
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_______________
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_______________________
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_______________________________
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_______________
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Sworn (or affirmed) at _________________
in the County of ______________________
this ____day of _____________,
______ before me
______________________________ _____________________________
Deputy Returning Officer Applicant
The Voters List may be used in future municipal, provincial or federal elections.
(Date of birth will be removed from final list of electors.)
________________________________________________________________
Form 31A: [repealed]
________________________________________________________________
Form 31B: Oath or Affirmation of Elector Not on List of Electors on Polling Day
(Where elector can vote only for Conseil scolaire acadien provincial)
(Section 98)
I swear (or solemnly affirm) that:
1. On this date, I actually reside in Polling Division Number ________ of the Town/
Municipality/Regional Municipality of _____________________________________ (the
“Municipality”).
2. As of the first advance polling day in this election, I have been ordinarily resident in:
• the Province of Nova Scotia for a period of six (6) months; and
• in the school region of the Municipality in which my polling division is located.
3. I have not previously voted before in this election at any other polling place, and I will not
(or will not attempt to) vote at any other polling place.
4. As of the first advance polling day, I was a Canadian citizen and of the full age of eighteen
years.
5. I am not the returning officer, a person serving a sentence in a penal or reform institution, or
a person convicted of bribery under the Municipal Elections Act in the six years preceding
ordinary polling day.
6. I wish to be added to the list of electors for the purpose of voting in this election.
Name of Elector
(please print)
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Civic Address of Elector
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Date of Birth
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_______________________
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_____________________________
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________________
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_______________________
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_____________________________
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________________
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Sworn (or affirmed) at _________________
in the County of ______________________
this ____day of _____________,
______ before me
___________________________________ _____________________________
Deputy Returning Officer Applicant
(A translation of this form is available in French)
The Voters List may be used in future municipal, provincial or federal elections.
(Date of birth will be removed from final list of electors.)
________________________________________________________________
Form 31C [repealed]
Form 31D [repealed]
________________________________________________________________
Form 32: Affidavit of Proxy Voter
(Section 99)
I swear (or solemnly affirm) that,
I am the proxy voter named in the proxy paper issued to the following elector whose name
appears on the list of electors for this polling station and whose name precedes my signature:
Name of Elector
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Address of Elector
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Signature of Proxy Voter
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Sworn (or affirmed) at __________________________
in the County of _______________________________
this _________ day of __________________________
_______________, before me
_________________________________________
Deputy Returning Officer
________________________________________________________________
Form 33: Statement of Poll (One Candidate or Matter)
(Sections 106, 111, 119)
(For use when only one candidate to be elected or one matter to be determined)
Municipality:
Polling District:
Polling Station No.:
Election for: Date:
1. Number of blank ballots received from Returning Officer
2. Add number of ballots from advance poll (if any)
3. TOTAL BALLOTS TO BE ACCOUNTED FOR *
4. Number of ballots taken from polling station (if any)
5. Number of unused ballots
6. Number of cancelled ballots (ones not placed in ballot box)
7. Number of rejected ballots (rejected during counting)
8. Number of ballots counted for ___________________
9. Number of ballots counted for ___________________
10. Number of ballots counted for ___________________
11. Number of ballots counted for ___________________
12. Number of ballots counted for ___________________
13. Number of ballots counted for ___________________
14. Number of ballots counted for ___________________
15. Number of ballots counted for ___________________
16. Number of ballots counted for ___________________
17. Number of ballots counted for ___________________
18. Number of ballots missing (if any)
19. TOTAL BALLOTS ACCOUNTED FOR *
*Note: Lines 3 and 19 must balance
Number of names on the final list of electors used at the polling
station plus electors sworn in at the polling station and added to
the list (if any)
Dated at _________________ this ________ day of _______________, ______
Approved: We certify that the above statement is correct
____________________________ _________________________________
Deputy Returning Officer
____________________________ _________________________________
Poll Clerk
________________________________________________________________
Form 34: Statement of Poll (More Than One Candidate or Matter)
(Sections 106, 111, 119)
(For use where more than one candidate is to be elected for the office or more than one matter is
to be determined from the ballot)
Municipality: _________________________________________
Polling District: _______________________________________
Polling Station No.: ____________________________________
Election for: ______________________ Date: ______________
1. __________ Number of blank ballots received from Returning Officer
2. __________ Add number of ballots from advance poll (if any)
3. *_________ TOTAL BALLOTS TO BE ACCOUNTED FOR
4. __________ Number of ballots taken from polling station (if any)
5. __________ Number of unused ballots
6. __________ Number of cancelled ballots (ones not placed in ballot box)
7. __________ Number of rejected ballots (rejected during counting)
8. __________ Number of ballot papers counted and accepted
9. __________ Number of ballot papers missing (if any)
10. *_________ TOTAL BALLOTS ACCOUNTED FOR
*Note: Lines 3 and 10 must balance
Ballots Cast For
Name of Candidate
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Number of Ballots Counted
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Number of names on the final list of electors used
at the polling station, plus electors sworn in at the
polling station and added to the list (if any) ___________________________________
Dated at __________________ this ________ day of ______________, ______.
Approved: We certify that the above statement is correct
___________________________ ______________________________
Deputy Returning Officer
___________________________ ______________________________
Poll Clerk
________________________________________________________________
Form 34A: Statement of Poll to be Completed when Conseil scolaire acadien provincial
Ballots to be Transferred for Counting
(Section 123A)
Municipality:
Polling District:
Polling Station No.:
Election for: Date:
1. Number of blank ballots received from Returning Officer
2. Add number of ballots from Advance Poll (if any)
3. TOTAL BALLOTS TO BE ACCOUNTED FOR *
4. Number of ballots taken from the polling station (if any)
5. Number of ballots missing (if any)
6. Number of unused ballots
7. Number of cancelled ballots (ones not placed in the ballot box)
8. Number of ballots cast at polling station for this office
(ones placed in the ballot box) ♦
9. TOTAL BALLOTS ACCOUNTED FOR *
*Note: Lines 3 and 9 must balance
10. TOTAL BALLOTS BEING TRANSFERRED ♦
♦Note: Lines 8 and 10 must balance
Dated at _______________ , this ____ day of ______________ , _______.
Approved: We certify that the above statement is correct
___________________________ ______________________________
Deputy Returning Officer
___________________________ ______________________________
Poll Clerk
________________________________________________________________
Form 35: Tally Sheet For the Counting of Votes
(Section 107)
To be used by the Deputy Returning Officer or the poll clerk and the candidates’ agents at the
counting of the votes cast for the various candidates on polling day. A cross or check mark of
any kind will be made consecutively in the small squares under the name of the candidate, in the
appropriate column, as each vote is called out by the Deputy Returning Officer.
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Column of
Votes Cast for
......................
(name of
Candidate)
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Column of
Votes Cast for
.......................
(name of
Candidate)
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Column of
Votes Cast for
.......................
(name of
Candidate)
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Column of
Votes Cast for
......................
(name of
Candidate)
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Column of
Votes Cast for
........................
(name of
Candidate)
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Column of
Votes Cast for
......................
(name of
Candidate)
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Column of
Votes Cast for
........................
(name of
Candidate)
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5
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10
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10
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15
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15
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20
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20
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25
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25
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30
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30
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35
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35
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40
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40
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45
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45
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50
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50
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55
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55
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60
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60
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65
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65
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70
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70
|
75
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75
|
80
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80
|
85
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85
|
90
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90
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95
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95
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100
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100
|
105
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105
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110
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110
|
________________________________________________________________
Form 35A: Tally Sheet for the Counting of Votes/Plebiscite
(Section 107)
To be used by the Deputy Returning Officer or the poll clerk at the counting of the votes cast for
the plebiscite on polling day. A cross or check mark of any kind will be made consecutively in
the small squares under the question number, in the appropriate column, as each vote is called
out by the Deputy Returning Officer.
Column of
Votes Cast for
.......YES........
|
Column of
Votes Cast for
......NO.......
|
5
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10
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15
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20
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25
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30
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35
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40
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45
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50
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55
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60
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65
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70
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75
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80
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85
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90
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95
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100
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|
________________________________________________________________
Form 36: Tally Sheet for the Counting of Votes At a Plebiscite
(Section 107)
To be used by the Deputy Returning Officer or the poll clerk and the candidates’ agents at the
counting of the votes cast for a plebiscite on polling day. A cross or check mark of any kind will
be made consecutively in the small squares under the question number, in the appropriate
column, as each vote is called out by the Deputy Returning Officer.
Column of
.......YES........
|
Column of
......NO.......
|
|
Column of
..... YES ....
|
Column of
..... NO .....
|
5
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5
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10
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10
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15
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15
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20
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20
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25
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25
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30
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30
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35
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35
|
40
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40
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45
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45
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50
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50
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55
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55
|
60
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60
|
65
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65
|
70
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70
|
75
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75
|
80
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80
|
85
|
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85
|
90
|
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90
|
95
|
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95
|
100
|
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|
|
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|
100
|
105
|
|
|
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|
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|
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|
105
|
110
|
|
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|
110
|
________________________________________________________________
Form 37: Persons Who Have Voted at the Advance Poll
(Section 117)
Advance Polling Station _______ comprising Policing [Polling] Division Numbers
__________________ to ___________________________.
Name of Elector
|
Polling Division
Number
|
Elector’s
Number on List
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
The number of electors who voted in this polling stations is ___________________.
Dated at ____________________________ this _________ day of
____________________________, ______.
______________________________________________
Deputy Returning Officer
________________________________________________________________
Form 38: Recapitulation Sheet
(Section 128)
Recapitulation Sheet
Note: “Rejected Ballots” are only those cast but not counted. Do not enter cancelled ballots on this sheet
|
POLLING STATION
|
Number of
Names on
Final
List of
Electors
plus
Electors
added to
the List
|
BALLOTS CAST FOR CANDIDATES
Names of Candidates
|
Rejected
Ballots
|
Number
of
Polling
Division
|
Name
or
Number of
Polling
District
|
Location of Polling
Station
|
|
|
|
|
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|
Total
|
|
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|
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|
|
|
|
|
|
I certify that the foregoing statement is the correct result of the polling at the election held on the
____________________ day of ____________________, 20_______
Dated at ______________________________ this _______________ day of _______________, 20_______
Sheet Number ________________
______________________________________
Returning Officer
|
________________________________________________________________
Form 38A [repealed]
________________________________________________________________
Form 39: Council Member’s Oath of Allegiance and of Office
(Section 147)
I, ____________________________, swear (or solemnly affirm) that I will be faithful and bear
true allegiance to His Majesty King Charles the Third, His heirs and successors according to law;
(the name of and reference to the sovereign to be changed as occasion requires.)
And that I am duly qualified as required by law for the office of ________________ of the
________________ of ________________;
And that I will truly, faithfully and impartially execute the duties of the office to which I have
been elected to the best of my knowledge and ability;
And that I have not received and will not receive any payment or reward or promise thereof for
the exercise of any partiality or other undue execution of the duties of my office.
Sworn (or affirmed) at ________________
in the County of _____________________
this _____ day of ____________________,
_______, before me
__________________________________
Judge, Justice of the Peace
(or for council members, also Mayor, Warden or Clerk)
________________________________________________________________
Form 40: Candidate’s Campaign Contributions Disclosure Statement
(Sections 49A and 49B)
Name of Candidate: ____________________________________________________________
Name of Agent: ________________________________________________________________
Date of Election: ______________ Municipality/CSAP: __________________________
☐ I received no contributions from a contributor that totalled more than $50.00 during the
period since the previous election.
OR
☐ I received the following contributions from a contributor that totalled more than $50.00
during the period since the previous election.
List of contributors (see note below):
Contributor Civic Address Contributions
________________________ _______________________ _______________________
________________________ _______________________ _______________________
________________________ _______________________ _______________________
________________________ _______________________ _______________________
________________________ _______________________ _______________________
Note: Insert full name of contributor and residential or business address. Use street
address, not postal address. Contributions must be shown for every contributor whose
contributions totalled more than $50.00 since the most recent election.
I, _________________________________, a candidate in the municipal/CSAP election on
__________________ (date), certify that the foregoing statement of disclosure is a true and
complete disclosure of all contributions made to me and to my official agent as required by
Sections 49A and 49B of the Municipal Elections Act.
_____________________________________
Candidate
(To be filed within 60 days after regular polling day with the clerk of the municipality/secretary
of CSAP)
(A translation of this form is available in French.)
________________________________________________________________
Form 41: Association’s Campaign Contributions Disclosure Statement
(Sections 49A and 49B)
Name of Association: _____________ ______________________________________________
Name of agent: ________________________________________________________________
Name of candidate supported: _____________________________________________________
Date of election: _____________ Municipality/CSAP: ___________________________
☐ The above-named candidate received no contributions from a contributor that totalled more
than $50.00 during the period since the previous election.
OR
☐ The candidate received the following contributions from a contributor that totalled more
than $50.00 during the period since the previous election.
List of contributors (see note below):
Contributor Civic Address Contributions
________________________ _______________________ _______________________
________________________ _______________________ _______________________
________________________ _______________________ _______________________
________________________ _______________________ _______________________
________________________ _______________________ _______________________
Note: Insert full name of contributor and residential or business address. Use street
address, not postal address. Contributions must be shown for every contributor whose
contributions totalled more than $50.00 since the most recent election.
I, _______________________________, the appointed agent of _________________________
(name of association) in the municipal/CSAP election on __________________ (date), certify that the
foregoing statement of disclosure is a true and complete disclosure of all contributions made to
me as agent of the said association as required by Sections 49A and 49B of the Municipal
Elections Act.
_____________________________________
Agent of Association
(To be filed within 60 days after regular polling day with the clerk of the municipality/secretary
of CSAP)
(A translation of this form is available in French.)
________________________________________________________________
Form 42 [repealed]
Form 43 [repealed]
________________________________________________________________
Form 44: Statement of Poll, Consolidated Count of Conseil scolaire acadien provincial Ballots
(One Member to be Elected from the CSAP Electoral District)
(Section 123A)
(For use when the ballots from polls with fewer than 10 votes for a CSAP
office are counted by a counting officer)
CSAP Electoral District
Number of Polls to be Counted (# of envelopes to be opened and counted)
1. Total Number of Ballots to be Counted
(from endorsements on each envelope from
each polling station) *
2. Number of Rejected Ballot Papers
3. Number of Ballot Papers Counted and Accepted
4. Number of Ballot Papers Missing (if any)
(#1 minus #3)
5. Additional Ballot Papers (if any)
(#3 minus #1)
6. Total Ballots to be Accounted for *
(Note: Lines 1 and 6 must balance.)
7. Number of Ballots counted for
Number of Ballots counted for
Number of Ballots counted for
Number of Ballots counted for
Number of Ballots counted for
8. TOTAL BALLOTS ACCOUNTED FOR *
(Note: Lines 6 and 8 must balance.)
Dated at _________________, this _______ day of _____________, ______.
Approved I certify that the above statement is correct
__________________________________
Counting Officer
________________________________________________________________
Form 45: Statement of Poll, Consolidated Count of Conseil scolaire acadien provincial Ballots
(More than One Member to be Elected from the CSAP Electoral District)
(Section 123A)
(For use when the ballots from polls with fewer than 10 votes for a CSAP
office are counted by a counting officer)
CSAP Electoral District
Number of Polls to be Counted (# of envelopes to be opened and counted)
1. Total Number of Ballots to be Counted
(from endorsements on each envelope from each
polling station) *
2. Number of Rejected Ballot Papers
3. Number of Ballot Papers Counted and Accepted
4. Number of Ballot Papers Missing (if any)
(#1 minus #3)
5. Additional Ballot Papers (if any)
(#3 minus #1)
6. Total Ballots to be Accounted for *
(Note: Lines 1 and 6 must balance.)
7. Names of Candidates Number of Ballots (Votes)
8. TOTAL BALLOTS ACCOUNTED FOR *
(Note: Lines 6 and 8 must balance.)
Dated at _________________, this _______ day of _____________, ______.
Approved I certify that the above statement is correct
Counting Officer
________________________________________________________________
Form 46: Record of Objections
(Section 109)
No.
|
Objections Made
By
|
On Behalf of
(Name of Candidate)
|
Nature of Objection
|
How
Decided
|
|
|
|
|
|
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|
|
The following regulations are not
yet in force and are not included in the current consolidation: