THE FORMS REFERRED TO IN THE FOREGOING ORDER.

FORM A 1.-Statement of Claim to Vote for Guardians of the Poor, in respect of Rateable Property in actual
Occupation of the Party Claiming.*

*This Form is adapted to the case of an Occupier claiming to Vote as Owner of the Property which he occupies, or in respect of excess of the Net Annual
Value of the Property over the rent which he pays; and when Corporations or Joint Stock Companies claim as Occupiers, this Form may also be used.
A rate-payer in actual occupation of the property, cannot appoint a proxy; and if the Electoral Division be subdivided into Wards, the votes can only
be given in the Wards containing the property, and a separate statement for each Ward will be necessary; in such case the name of the Ward must be
written at the head of the statement, and the Returning Officer will issue a Voting Paper for each Ward.
Or, The (b)
+ Board of Guardians, or the Returning Officer. (a) Name of Union. b) Name, if an Individual; or title of Corporation or Joint Stock Company:
Company claims. (c) Place of Abode, if an Individual. (d) Title, Profession, Trade, or Employment, if an Individual. (e) Name
of Electoral Division and Ward, when divided into Wards. (f) When the Property is situate in a City, Town, or its Suburbs, having Streets and other
Roadways, the name of the Street or Roadway, and the Number of the House or Tenement, if any, and the Parish in which the Property is situate, are
required to be stated; and in other places the Barony, Parish, and Townland. (g) Farm, House, or Warehouse, &c. (h) Give the name of the House, if
nt in a Town; in all other cases the name of the Street and the Number of the House, or some certain reference to it. The House must be in the
Division or Ward for which the claim to vote is made. (1) [And the Officer directed by the said (b)
to vote on behalf of the said (b)

-.] This clause is only to be used in the case of Corporations or Joint Stock Companies, who are to name the Officer who is to vote.

FORM A 2.-Statement of Claim to Vote in Person, for Guardians of the Poor, by a Landlord entitled to Rents exceeding the Rents payable, or by an Owner of Tithe Rent-charges.

Union.

of (c)

(d)

Union.

[

Ward.*]

claim to vote in the Election of Guardians, according to the provisions of the Acts in the Destitute Poor in Ireland, being entitled thereto in respect of the Property hereinafter described, which is situate Electoral Division of the (a) Union, that is to say :

Situation of Property (ƒ).

Names of Tenants

Nature

Barony.

Parish.

Townland.

Street or Roadway, if in
a City, Town, or Suburbs,
with No. of House or
Tenement, if any.

or Occupiers (if any), Description of the Rate-Value accord-
by whom Poor Rates of Property.
(g)
have been deducted
from Rent.

Net Annual

payer's
Interest

ing to the Valuation.

Rent
receivable.

Rent
payable.

therein.

Annual
Amount of
Net Rent, or
Net Tithe
Rent-charge.

The place in the above Electoral Division, at which a Voting Paper may be left and called for, is the house (h)
Given this day of

18-.

Signed in the presence of

(Signature).
(Signature),

Justice of the Peace.
* If the Electoral Division be subdivided into Wards, it will be necessary to make a distinct statement for each Ward in which the Property, in
respect of which the claim is made, is situate; in each case naming the Ward at the head of the paper, and the Returning Officer will issue a Voting
Paper for each Ward.

† Board of Guardians, or the Returning Officer. (a) Name of Union. (b) Name of Landlord or Owner of Tithe Rent-charges, if an Individual; or
title of Corporation or Joint Stock Company: Or, The (b)
Company claims. (c) Place of Abode, if an Individual. (d) Title, Profession, Trade,
or Employment, if an Individual. (e) Name of Electoral Division, and of Ward, when divided into Wards. (f) When the property is situate in a City,
Town, or its Suburbs, having Streets and other Roadways, the name of the Street or Roadway, and the Number of the House or Tenement, if any, and
the Parish in which the Property is situate, are required to be stated; and in other places the Barony, Parish, and Townland. (g) House, Farm, or
Warehouse, &c., as the case may be; or Tithe Rent-charge. (h) Give the name of the House, if not in a Town; in all other cases the name of the
Street, and the Number of the House, or some certain reference to it. The House must be in the Division or Ward for which the claim to vote is made.
And the Officer directed by the said (b)
to vote on behalf of the said (b))
.] This clause is only to be used in the case

of Corporations or Joint Stock Companies, who are to name the Officer who is to vote.

is

FORMS B 1 and 2.

FORM B 2.-Application of Proxy thereupon.

I,

—of

To the‡

having been appointed by

of the

of

Union.

to Vote in the Election of Guardians as his Proxy,
under the provisions of the Acts in force for the Relief of the Destitute Poor in Ireland, in respect of Property situate
Union (d), do hereby claim to be entitled to Vote as such Proxy. I
within the
setting forth the particulars required by law,
signed by the said

Electoral Division of

hereby transmit to you such my appointment,

is entitled to Vote, and in respect of which I do hereby claim to
of the Property in respect of which the said
Vote as his Proxy; and I appoint as the place at which a Voting Paper for me may be left and called for, the

(d) Or, the

Ward of the ·Electoral Division of

Board of Guardians, or, the Returning Officer.

Union.

(e) Give the name of the House, if not in a Town; in all other cases the name of the Street, and the Number of the House, or some certain reference to it. The House must be in the Division or Ward for which the claim to Vote is made.

To the†

[

Ward.*]

Situation of Property (ƒ).

Street or Roadway, if in
Townland. aCity, Town, or Suburbs,
with No. of House, or
Tenement, if any.

Given this The place in the above Electoral Division, at which a Voting Paper may be left and called for, is the house (h)