New South Wales Consolidated Regulations

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LOCAL GOVERNMENT (GENERAL) REGULATION 2005 - SCHEDULE 11

SCHEDULE 11 – Forms

Form 1 - Request for omission or removal of place of living from roll (non-resident electors)

(Clause 284)

To the General Manager, [here specify local government area]

In reference to my enrolment in [ward], [local government area]

I, [surname in BLOCK letters], [other names in BLOCK letters]
of [full residential address]
request that *my residential address/*the following matter that would disclose or discloses my place of living be omitted or removed from the roll of electors for the abovementioned area (* cross out whichever does not apply):
[here specify any other matter that would disclose or discloses the place of living].

The disclosure of my place of living on those rolls would place or places my personal safety or that of members of my family at risk. The following are particulars of the relevant risk [state particulars]:

[signature of applicant]

[date]

Note :
1 This request must be verified by statutory declaration by the person making the request or by another person. The form of statutory declaration on the back of this form may be used for this purpose.
2 Resident electors who wish to have their address or other matter removed from the electoral roll must make an application to the Australian Electoral Commission or the State Electoral Office.

Request for omission or removal of place of living from roll (non-resident electors)

STATUTORY DECLARATION

I, [full name in BLOCK letters], of [full address],
do solemnly and sincerely declare as follows [make declaration]:

And I make this solemn declaration conscientiously believing the same to be true, and by virtue of the provisions of the Oaths Act 1900 .

[signature of person making the declaration]

Declared before me at [place], [date]

Justice of the Peace

Request for omission or removal of place of living from roll (non-resident electors)

Certificate under section 34 (1) (c) of

* Please cross out any text that does not apply

I [insert name of witness], a Justice of the Peace, certify the following matters concerning the making of this statutory declaration by the person who made it:

1 *I saw the face of the person or *I did not see the face of the person because the person was wearing a face covering, but I am satisfied that the person had a special justification for not removing the covering.
2 *I have known the person for at least 12 months or *I have confirmed the person's identity using an identification document and the document I relied on was [describe identification document relied on].

[insert signature of witness]

Date:

Form 2 - Nomination paper: proposal by electors

(Clause 289 (1) (a))

WE, the undersigned persons enrolled for the election to be held in [name of ward and area or name of area alone, as appropriate]
on [date], hereby propose for nomination as a candidate at that election for the office of
[here specify whether as councillor or mayor]
[full name in BLOCK letters] of [full residential address], [occupation]

[full name of proposer in BLOCK letters] [full name of proposer in BLOCK letters]
[signature of proposer] [signature of proposer]
[address of proposer] [address of propose d]
[date] [date]

Nomination paper: proposal by electors

FORM OF CONSENT

I, the abovenamed [full name of person proposed for nomination in BLOCK letters]
hereby:

1 declare that, to the best of my knowledge and belief, *I was enrolled as an elector for the area on [the closing date for the election]/*my name has been mistakenly or accidentally omitted from the roll of electors [* cross out whichever does not apply],
2 consent to my being proposed for nomination,
3 request that my name should be printed on the ballot-papers for the election in the following form:
[surname in BLOCK letters, given name in BLOCK letters]
4 *request/*do not request that the word "Independent" be printed adjacent to my name on the ballot-papers [* cross out whichever does not apply].
5 declare that, to the best of my knowledge and belief, *I am/*I am not a property developer, being a person engaged in a business that regularly involves the making of relevant planning applications by or on behalf of the person in connection with the residential or commercial development of land, with the ultimate purpose of the sale or lease of the land for profit [* cross out whichever does not apply],
6 declare that, to the best of my knowledge and belief, *I am/I am not a close associate of a corporation that is a property developer [* cross out whichever does not apply].

[signature of person proposed for nomination]

Note :
1 See the back of this Form [or the attached page] for the provisions of the Local Government Act 1993 covering qualification and disqualification for a civic office.
2 An alternative form of a candidate's given name may only be:
(a) an initial standing for that name, or
(b) a commonly accepted variation of the name (including an abbreviation or truncation of that name or an alternative form of that name), or
(c) a commonly used other name specific to the candidate by which the candidate is usually identified (if the returning officer is satisfied that the proposed name is a commonly used other name specific to the candidate by which the candidate is usually identified).
3 A person must not propose for nomination more than one candidate for election as mayor in the area, or more candidates for election as councillors in the ward or area than the total number of councillors to be elected for that ward or area (eg if five councillors are to be elected for an area, a person must not propose more than five persons for nomination as councillor for that area).
4 In item 5, a "relevant planning application" has the same meaning as in section 147 (Disclosure of political donations and gifts) of the Environmental Planning and Assessment Act 1979 .
5 In item 6, a "close associate" of a corporation means each of the following:
(a) a director or officer of the corporation or a related body corporate of the corporation or the spouse of such a director or officer,
(b) a person whose voting power in the corporation or a related body corporate of the corporation is greater than 20% or the spouse of such a person,
(c) if the corporation is a trustee, manager or responsible entity in relation to a trust--a person who holds more than 20% of the units in the trust (in the case of a unit trust) or is a beneficiary of the trust (in the case of a discretionary trust),
(d) if the corporation or a related body corporate of the corporation is a stapled entity in relation to a stapled security--a person who holds more than 20% of the units in the trust that is the other stapled entity.

Nomination paper: proposal by electors

STATISTICAL INFORMATION SHEET

(Complete this sheet for ordinary elections only, not by-elections)

I, (full name in BLOCK letters)
of (full residential address),
declare that:

(tick the squares that apply and insert other information as indicated)

(a) I am male □ female □
(b) I am 18-24 years old
25-29 years old
30-39 years old
40-49 years old
50-59 years old
60-69 years old
70-79 years old
80 years or older
(c) I was a candidate at the last ordinary election of the council
Yes □ No □
(d) I was elected at the last ordinary election of the council
Yes □ No □
(e) My experience as a councillor in New South Wales is□ I have not served as a councillor before□ I was elected but served less than 1 complete term□ I completed 1 term□ I completed 2 terms□ I completed 3 terms□ I completed 4 terms□ I completed 5 terms□ I completed more than 5 terms (please specify)
(f) I consider myself to be an Aboriginal person
Yes □ No □
(g) I consider myself to be a Torres Strait Islander person
Yes □ No □
(h) I consider myself to have a disability
Yes □ No □
(i) The first language I learned to speak was
English
Arabic
Cantonese
Dutch
German
Greek
Italian
Lebanese
Mandarin
Vietnamese
Other □ (please specify)
(j) My current occupation is
Professional
Manager
Primary Producer/Farmer
Para-Professional/Tradesperson
Property Developer
Clerk
Salesperson
Real Estate Agent
Labourer
Plant/Machine Operator
Home Duties
Self-employed
Student
Retired
Unemployed
Other □ (please specify)
(k) I am a member of the following registered political parties (being political parties registered under the Parliamentary Electorates and Elections Act 1912 or under the Local Government Act 1993 ):
(l) I am a property developer or a close associate of a corporation that is a property developer (within the meaning of clause 290 of the Local Government (General) Regulation 2005 )
Yes □ No □

Note : The information supplied above will be used for statistical purposes only. This information will be treated confidentially. All statistics will be published in aggregate or consolidated form only.

Form 3 - Nomination paper: proposal by registered officer for party

(Clause 289 (1) (b))

I, the person whose name appears on this form as the registered officer for the political party (registered in the Local Government Register of Political Parties) that has endorsed the person proposed for nomination, hereby propose for nomination [here state name in full in BLOCK letters, occupation and full residential address of the person proposed for nomination] as a candidate at the election to be held in [name of ward and area or name of area alone, as appropriate] on [date] for the office of [here specify whether as councillor or mayor].

I request that the *registered name/*abbreviated name of the party be printed adjacent to the candidate's name on the ballot-papers [* cross out whichever does not apply].

Dated

Name in full of registered officer Name of political party Signature of registered officer

Nomination paper: proposal by registered officer for party

FORM OF CONSENT

I, the abovenamed [full name of person proposed for nomination in BLOCK letters],
hereby:

1 declare that, to the best of my knowledge and belief, *I was enrolled as an elector for the area on [the closing date for the election]/*my name has been mistakenly or accidentally omitted from the roll of electors [* cross out whichever does not apply],
2 consent to my being proposed for nomination,
3 request that my name should be printed on the ballot-papers for the election in the following form:
[surname in BLOCK letters, given name in BLOCK letters]
4 declare that, to the best of my knowledge and belief, *I am/*I am not a property developer, being a person engaged in a business that regularly involves the making of relevant planning applications by or on behalf of the person in connection with the residential or commercial development of land, with the ultimate purpose of the sale or lease of the land for profit [* cross out whichever does not apply],
5 declare that, to the best of my knowledge and belief, *I am/I am not a close associate of a corporation that is a property developer [* cross out whichever does not apply].

[signature of person proposed for nomination]

Note :
1 See the back of this Form [or the attached page] for the provisions of the Local Government Act 1993 covering qualification and disqualification for a civic office.
2 An alternative form of a candidate's given name may only be:
(a) an initial standing for that name, or
(b) a commonly accepted variation of the name (including an abbreviation or truncation of that name or an alternative form of that name), or
(c) a commonly used other name specific to the candidate by which the candidate is usually identified (if the returning officer is satisfied that the proposed name is a commonly used other name specific to the candidate by which the candidate is usually identified).
3 In item 4, a "relevant planning application" has the same meaning as in section 147 (Disclosure of political donations and gifts) of the Environmental Planning and Assessment Act 1979 .
4 In item 5, a "close associate" of a corporation means each of the following:
(a) a director or officer of the corporation or a related body corporate of the corporation or the spouse of such a director or officer,
(b) a person whose voting power in the corporation or a related body corporate of the corporation is greater than 20% or the spouse of such a person,
(c) if the corporation is a trustee, manager or responsible entity in relation to a trust--a person who holds more than 20% of the units in the trust (in the case of a unit trust) or is a beneficiary of the trust (in the case of a discretionary trust),
(d) if the corporation or a related body corporate of the corporation is a stapled entity in relation to a stapled security--a person who holds more than 20% of the units in the trust that is the other stapled entity.

Nomination paper: proposal by registered officer for party

STATISTICAL INFORMATION SHEET

(Complete this sheet for ordinary elections only, not by-elections)

I, (full name in BLOCK letters)
of (full residential address),
declare that:

(tick the squares that apply and insert other information as indicated)

(a) I am male □ female □
(b) I am 18-24 years old
25-29 years old
30-39 years old
40-49 years old
50-59 years old
60-69 years old
70-79 years old
80 years or older
(c) I was a candidate at the last ordinary election of the council
Yes □ No □
(d) I was elected at the last ordinary election of the council
Yes □ No □
(e) My experience as a councillor in New South Wales is□ I have not served as a councillor before□ I was elected but served less than 1 complete term□ I completed 1 term□ I completed 2 terms□ I completed 3 terms□ I completed 4 terms□ I completed 5 terms□ I completed more than 5 terms (please specify)
(f) I consider myself to be an Aboriginal person
Yes □ No □
(g) I consider myself to be a Torres Strait Islander person
Yes □ No □
(h) I consider myself to have a disability
Yes □ No □
(i) The first language I learned to speak was
English
Arabic
Cantonese
Dutch
German
Greek
Italian
Lebanese
Mandarin
Vietnamese
Other □ (please specify)
(j) My current occupation is
Professional
Manager
Primary Producer/Farmer
Para-Professional/Tradesperson
Property Developer
Clerk
Salesperson
Real Estate Agent
Labourer
Plant/Machine Operator
Home Duties
Self-employed
Student
Retired
Unemployed
Other □ (please specify)
(k) I am a member of the following registered political parties (being political parties registered under the Parliamentary Electorates and Elections Act 1912 or under the Local Government Act 1993 ):
(l) I am a property developer or a close associate of a corporation that is a property developer (within the meaning of clause 290 of the Local Government (General) Regulation 2005 )
Yes □ No □

Note : The information supplied above will be used for statistical purposes only. This information will be treated confidentially. All statistics will be published in aggregate or consolidated form only.

Form 4 - Ballot-paper

(Clause 305 (8))

[insert name of ward if applicable] [insert name of area]

Election of [here insert the number of vacancies that the election is being held to fill and whether the election is of councillors or of the mayor] held on [insert election day].

Ballot-paper

Candidates

[If the returning officer has accepted an application to print the name of a political party or the word "Independent" adjacent to the name of a candidate, the name or word must be printed there.]

VALADON, Susan
(Blackacre)
ARRAIZA, Ramon
VALADON, Sue
(Tenterfield)
BROWN, Denise
KABOS, Colin
DAVIS, Ron
(Storekeeper, Tenterfield)
DAVIS, Ron
(Grazier, Tenterfield)
HO, Liam
MAHON, Sharon
WHITMORE, Kim

[The following directions are to appear on the front or the back of the ballot-paper. If the directions appear on the back of the ballot-paper, an appropriate reference to their appearance on the back must be made on the front of the ballot-paper.]

Ballot-paper

[Here insert the following directions if only one candidate is to be elected]

Place the number "1" in the square next to the candidate of your choice.

If you wish to vote for any more candidates, place consecutive numbers starting with "2" in the squares next to those candidates in order of your preferences for them. [This second direction should only be inserted if there are more than 2 candidates]

[Here insert the following directions if 2 or more candidates are to be elected]

Place the numbers [here insert the sequence of numbers that corresponds to half the number of candidates to be elected] in the squares next to the [here insert half the number of candidates to be elected] candidates in order of your preferences for them.

If you wish to vote for any more candidates, place consecutive numbers starting with [here insert the next number after half the number of the candidates to be elected] in the squares next to those candidates in order of your preferences for them. [Where half the number to be elected is a fraction it is to be rounded up to the next integer]

ELECTORS PLEASE NOTE: YOU MUST NOT TAKE A BALLOT-PAPER OUT OF THE POLLING PLACE.

Form 5 - Ballot-paper

(Clause 305 (8))

[insert name of ward if applicable] [insert name of area]

Election of [here insert the number of vacancies that the election is being held to fill] councillors held on [insert election day]

Ballot-paper

Candidates

GROUP A GROUP B GROUP C
□ VALADON,
Susan
(Blackacre)
*
□ BROWN,
Denise
**
□ DAVIS,
Ronald
(Storekeeper,
Tenterfield)
*
□ MAHON
Sharon
***
□ ARRAIZA,
Ramon
*
□ KABOS,
Colin
**
□ DAVIS,
Ronald
(Grazier,
Tenterfield)
*
□ WHITMORE,
Terence
***
□ VALADON,
Sue
(Tenterfield)
*
□ HO,
Liam
*

* Here insert name of registered party if to be printed.

** Here insert the word "Independent" if to be printed.

*** Here insert name of registered party or word "Independent" if to be printed.

[The following directions are to appear on the front or the back of the ballot-paper. If the directions appear on the back of the ballot-paper, an appropriate reference to their appearance on the back must be made on the front of the ballot-paper.]

Ballot-paper

Place the numbers [here insert the sequence of numbers that corresponds to half the number of candidates to be elected] in the squares next to the [here insert half the number of candidates to be elected] candidates in order of your preferences for them.

If you wish to vote for any more candidates, place consecutive numbers starting with (here insert the next number after half the number of the candidates to be elected) in the squares next to those candidates in order of your preferences for them. [Where half the number to be elected is a fraction it is to be rounded up to the next integer]

ELECTORS PLEASE NOTE: YOU MUST NOT TAKE A BALLOT-PAPER OUT OF THE POLLING PLACE.

Form 6 - Ballot-paper

(Clause 305 (8))

[insert name of ward if applicable] [insert name of area]

Election of [here insert the number of vacancies which the election is being held to fill] councillors held on [insert election day].

graphic

[Where half the number to be elected is a fraction it is to be rounded up to the next integer]

ELECTORS PLEASE NOTE: YOU MUST NOT TAKE A BALLOT-PAPER OUT OF THE POLLING PLACE.

Form 7 - (Repealed)

Form 8 - Postal vote declaration

(Clause 317)

Application No (official use only)

I [insert full name in BLOCK letters] declare that:

1 I have not already voted in connection with the forthcoming election being held on [date] in the [name of ward] ward of [local government area].
2 I am still entitled to vote at the election and the address of the land to which my voting entitlement relates (as resident, non-resident owner, occupier or ratepaying lessee) is:
[full address].
3 To the best of my knowledge and belief I am enrolled on the New South Wales or Commonwealth electoral roll.
4 The postal vote to which this declaration relates was completed before the close of the poll in the election.

[signature]

[date]

Postal vote declaration

WITNESSING OF DECLARATION

I am at least 18 years old and am not a candidate or an agent of a candidate at the abovementioned election, and

I am satisfied as to the identity of the elector, and

I have seen the elector sign the declaration, and

I know, or have satisfied myself by reasonable inquiry, that the statements contained in the declaration are true.

The declaration was made before the close of the poll in the election.

[signature of witness]

[address of witness]

[date]

Forms 9-14 - (Repealed)

Form 15 - Penalty notice--Failure to vote

(Clause 357)

Area Ward No on Roll
[Name and address]

The Electoral Commission's records indicate that you appear to have failed to vote at the election/constitutional referendum held on [date]

The maximum penalty for failing to vote is [insert maximum amount of penalty].

IF YOU DID VOTE:

Please complete and sign the following declaration.
I declare that I did vote at [polling place]
in respect of the election/constitutional referendum held on [date]

[signature]

IF YOU DID NOT VOTE:

1 If you think you have a sufficient reason for not voting, please complete and sign the following declaration:
I declare that I did not vote at the election/constitutional referendum held on [date] for the following reason:

[signature]

2 If you do not think you have a sufficient reason for not voting, you may dispose of the matter by:
• paying a penalty of [insert amount of penalty] to the Electoral Commission within 28 days of the date of this notice
OR
• having the matter dealt with by a court, where the maximum penalty is [insert maximum amount of penalty] and you may also have to pay court costs.

IF A DECLARATION OF VOTING IS NOT MADE, A REASON FOR NOT VOTING IS NOT GIVEN AND THE PENALTY IS NOT PAID WITHIN 28 DAYS, PROCEEDINGS MAY BE TAKEN AGAINST YOU IN COURT.

Penalty notice--Failure to vote

PROCEDURE FOR PAYMENT OF PENALTY OR OFFER OF EXPLANATION

Deliver or send the penalty or the explanation to the Electoral Commission at [address of Electoral Commission's Office]

Cheques and money orders should be crossed, marked not negotiable and made payable to the Electoral Commission.

DO NOT SEND CASH. PART PAYMENT OF THIS PENALTY CANNOT BE ACCEPTED.

The PENALTY for any person making a false statement in this Form is [insert maximum amount of penalty].

THIS FORM MUST BE DELIVERED OR SENT WITH YOUR PAYMENT OR EXPLANATION

Electoral Commission

□ TICK IF RECEIPT IS REQUIRED

[date]

Form 16 - Constitutional referendum or council poll paper

(Schedule 10, clause 4)

[local government area]
Constitutional referendum/council poll taken on [date]

Directions: The question below requires a "Yes" or "No" answer.
If you decide to answer "Yes" to the question, write the word "Yes" in the space provided opposite the question.
If you decide to answer "No" to the question, write the word "No" in the space provided opposite the question.
Question: [here set out question]



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