(See Rules 19 and 20)
To
The Returning Offlcer
For Assembly Constituency,
.............................
Sir,
I intend to cast my vote by post at the ensuing election to the Legislative Assembly from the..........................................................................Assembly Constituency.
My name Is entered at S. No. ............................................in Part No..........................of the electoral roll for ...........................................................Assembly Constituency.
The ballot paper may be sent to me at the following address:-
Yours faithfully,
Place :
Date :
Name :
XYZ :