13. Number of persons who have voted on production of

Election Duty Certificate (EDC) :

14. Number of electors who voted with the help of companions :

15. Number of tendered votes :

16. No. of electors-

(a) From whom declarations as to their age obtained ................

(b) Who refused to give such declaration .................

17. Whether it was necessary to adjourn the poll and if so, the

reasons for such adjournment :

18. Number of votes cast-

from 7 a.m. to 9 a.m.

from 9 a.m. to 11 a.m.

from 11 a.m. to 1 p.m.

from 1 p.m. to 3 p.m.

from 3 p.m. to 5 p.m.

19. Number of slips issued at the closing hour of the poll :

20. Electoral offences with details :

Number of cases of-

(a) canvassing within one hundred metres of a polling station :

(b) impersonation of voters :

(c) fraudulent defacing, destroying or removal of a list of notice or other document at a polling station.

(d) bribing of voters :

(e) intimidation of voters and other persons :

21. Was the poll interrupted or obstructed by-

(1) riot :

(2) open violence :

*This will include all the ballot papers issued at the polling station plus postal ballot papers issued to electors on election duty.

†This will include ballot papers cancelled and tendered ballot papers also.

(3) natural calamity :

(4) any other cause :

Please give details of the above.

22. Was the poll vitiated by-

(1) any ballot box used at the polling station having been unlawfully taken out of the custody of the Presiding Officer-

(a) accidentally or intentionally lost or destroyed :

(b) damaged or tampered with :

(2) the ballot papers having been unlawfully marked by any person and deposited in the ballot box :

Please give details

23. Serious complaints, if any, made by the candidate :

24. Number of cases of breach of law and order :

25. Report of mistakes and irregularities committed, if any, at the polling station :

26. Whether the declarations have been made before the commencement of the poll and if necessary during the course of poll when a new ballot box is placed for reception of marked ballot paper and at the end of poll as necessary :

Place :

Date :

Presiding Officer

This diary should be forwarded to the Returning Officer along with the ballot boxes and other sealed papers.