F1SI 1985/454
To be returned with the [ insert colour of ballot paper] coloured ballot paper No .
I hereby declare that I am the person to whom the [ insert colour of ballot paper] coloured ballot paper numbered as above was sent.
Voter's signature
The voter, who is personally known to me, has signed this declaration in my presence.
Witness's signature
Name of witness (WRITE CLEARLY)
Address of witness (WRITE CLEARLY)
SEE INSTRUCTIONS ON THE BACK OF THIS FORM