Schedule 11Forms

# Schedule 11 Forms Schedule 11 Forms Form 1 Request for omission or removal of place of living from roll (non-resident electors) (Section 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. 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](/view/html/inforce/current/act-1900-020). \[*signature of person making the declaration*\] Declared before me at \[*place*\], \[*date*\] Justice of the Peace **Certificate under section 34(1)(c) of [Oaths Act 1900](/view/html/inforce/current/act-1900-020)** \**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 (Section 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 proposed] | | [date] | [date] | 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 (within the meaning of Division 7 of Part 3 of the [Electoral Funding Act 2018](/view/html/inforce/current/act-2018-020)) \[*\*cross out whichever does not apply*\]. \[*signature of person proposed for nomination*\] Note. 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 Electoral Act 2017 or under the Local Government Act 1993)— | | (l) I am a property developer (within the meaning of Division 7 of Part 3 of the Electoral Funding Act 2018) | | | Yes □ | No □ | \[*signature of person proposed for nomination*\] 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 (Section 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 | | | | | | | | | | | | | 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 (within the meaning of Division 7 of Part 3 of the [Electoral Funding Act 2018](/view/html/inforce/current/act-2018-020)) \[*\*cross out whichever does not apply*\]. \[*signature of person proposed for nomination*\] Note. 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 Electoral Act 2017 or under the Local Government Act 1993)— | | (l) I am a property developer (within the meaning of Division 7 of Part 3 of the Electoral Funding Act 2018) | | | Yes □ | No □ | \[*signature of person proposed for nomination*\] 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 (Section 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 \[*insert election day*\]. *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 \[*The following directions are to appear on the front or the back of the ballot-paper. If the directions appear on the back of the ballot-paper, an appropriate reference to their appearance on the back must be made on the front of the ballot-paper.*\] Directions for Voting \[*Here insert the following directions if 1 or 2 candidates are to be elected*\] 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. \[*This second direction should only be inserted if there are more than 2 candidates*\] \[*Here insert the following directions if 3 or more candidates are to be elected*\] 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 (Section 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 \[*insert election day*\] *Candidates* | GROUP A | GROUP B | GROUP C | | | □ VALADON,Susan(Blackacre)* | □ BROWN,Denise** | □ DAVIS,Ronald(Storekeeper,Tenterfield)* | □ MAHONSharon*** | | □ 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. \[*The following directions are to appear on the front or the back of the ballot-paper. If the directions appear on the back of the ballot-paper, an appropriate reference to their appearance on the back must be made on the front of the ballot-paper.*\] Directions for Voting 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 (Section 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 \[*insert election day*\]. %20AND%20(No%3D0460)%20AND%20(Year%3D2021)%20AND%20(%22Historical%20Document%22%3D0))/g1.gif) \[*Where half the number to be elected is a fraction it is to be rounded up to the next integer*\] ELECTORS PLEASE NOTE: YOU MUST NOT TAKE A BALLOT-PAPER OUT OF THE POLLING PLACE. Form 15 Penalty notice—Failure to vote (Section 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/de-amalgamation 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/de-amalgamation 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/de-amalgamation 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. 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, de-amalgamation referendum or council poll paper Schedule 10, section 4 \[*local government area*\] Constitutional referendum/de-amalgamation 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, place a tick in the square next to the word “Yes”.If you decide to answer “No” to the question, place a tick in the square next to the word “No”. | | | | | | Question— | [here set out question] | | | | Yes □ | No □ | **sch 11:** Am 2021 (603), Sch 1\[4\]; 2025 (223), Sch 1\[19\]–\[21\].