[Consecutive Number] PAGE LINE NO. OFFICIAL MARK
Declaration by special voter who is overseas or on a fishing vessel
Special voter’s electorate
This must be the electorate in which you last resided continuously in New Zealand for at least one month
I believe I am qualified to vote in the electorate of:
OFFICIAL USE ONLY Index Reference
Show the ground or grounds that apply to you:
Tick circle(s) where applicable
(A) I am outside New Zealand, and (show the additional grounds that apply to you)
1. I am a New Zealand citizen and have been in New Zealand within the past 3 years; or
2. I am a permanent resident of New Zealand and have been in New Zealand within the last 12 months; or
3. I am carrying out my duties as: (a) public servant, or (b) a member of the Defence Force, or (c) a head of mission or head of post within the meaning of the Foreign Affairs Act 1988, or (d) an officer or employee of Trade New Zealand; or
4. I am accompanying a person described in category 3 above, and (a) I am the spouse, civil union partner, or de facto partner of that person, or (b) I am the child of that person, or (c) I am the child of the spouse, civil union partner or de facto partner of that person;
OR (B) I am on a fishing vessel that is not scheduled to return to port in the period between the close of nominations and the close of the poll;
OR (C) I am in the Ross Dependency.
Special voter’s details
Please PRINT clearly
My surname or family name is:
My full given or first names are:
My occupation is:
My contact telephone number is:
My date of birth is:
You do not have to show your date of birth but it will help with the checking of your enrolment if you do
Has your name changed since you enrolled?
No
Yes My former name was:
You do not have to show your former name but it will help with the checking of your enrolment if you do
My present residential address is: Not required for Ground B
Flat/House number Street/Road:
Town/City or Locality:
Country:
Show the last address in New Zealand at which you have resided continuously for at least on month:
Flat/House number Street/Road:
Town/City or Locality:
Declaration by special voter
For the grounds that I have indicated above, I am unable to attend a polling place in New Zealand on polling day.
I declare that to the best of my knowledge and belief the details given in this declaration are true.
Signature of special voter Date
OFFICIAL USE ONLY
Witness
I certify that the special voter signed the declaration in my presence.
Signature of witness
Is the witness the Issuing Officer?
Yes
OFFICIAL MARK IF WITNESS IS
ISSUING OFFICER
No
Give your details below
Details are only needed if witness is NOT the Issuing Officer
My surname or family name is:
My full given or first names are:
My residential address is:
Flat/House number Street/Road:
Town/City or Locality:
Country:
Show how you qualify as a witness: Tick one
Commonwealth Representative
Person authorised to take a statutory declaration in New Zealand
Commissioner of Oaths
Notary Public
Person approved by Returning Officer
Person authorised to administer an oath for the purpose of a judicial proceeding in the country in which the declaration is made
Relative, or member of the household, or business colleague or associate, of the special voter
Registered New Zealand elector