Form 13G
[See rule 27 N (4)]

Serial No………………….

Revocation of appointment of proxy or revocation of appointment of proxy and appointment of substitute proxy by classified Service voter to give vote.

I …………….................................……….. (name of the classified service voter) aged about ..… yrs is s/o, d/o, w/o .......................................... R/O  ....................................................…………….. presently working as ...........………………………. and posted at ………...............….. had appointed as ……............................... (name of the proxy) .... aged about ………..........…………. s/o, d/o, w/o ……………….....……… R/O………………………, as my proxy to give vote on my behalf and in my name in …………………………… Assembly constituency and /or ……………………….Parliamentary constituency of the State/Union territory of ………………………...

2.   I hereby revoke the appointment of my said proxy and do not wish to appoint any substitute proxy.

OR

Whereas such proxy has died/I hereby revoke appointment of the said proxy and being entitled to appoint substitute proxy under sub-rule (4) of rule 27N of the Conduct of Election Rules, 1961, hereby appoint (name of the substitute proxy) aged about……………………….. s/o, d/o, w/o …………….r/o…………………… as substitute proxy who shall hereafter give vote on my behalf and in my name in …………………………Assembly constituency and/or ……………………..Parliamentary constituency ……………… of the state /union territory of ………………………in which I am entitled to give vote under the Representation of the People Act, 1951(43 of 1951) and the rules made there under.

 

…………………….. ………….…………………....
(Signature of proxy) (Signature of classified Service voter)
Serial number of his name and Serial number of his name in the last
part no. of e1ectora1 roll of the  part of electoral roll of concerned
concerned constituency ………… constituency …………………..
  Service Identity Card No. ………………
  Name of the Force to which
  he belongs………………………………......

Note:-

(1) The person to be appointed as proxy shall be an ordinary resident in the constituency concerned and of not less than eighteen years of age and shall not be a person disqualified for registration as an elector in an electoral roll under section 16 of the Representation of the People Act, 1950(43 of 1950).

(2) The signature of the classified service voter and the proxy shall be made before a First Class Magistrate or Notary or the Commanding Officer of the Unit concerned who shall verify the signatures under his hand and seal. In case of First class Magistrate or Notary verifying the signature, he shall personally check the service identity card of the classified service voter to authenticate veracity of the classified service voter.

(3) Score out the word (s) which are not applicable

Receipt of Form 13G for the appointment of proxy by classified service voter
(To be handed over to the person depositing the said form)

Serial No……………….

Received Form 13G of Shri/Smt/Kum …………………………………..

 

Date ………………… . ……………………..
  Returning Officer