AR 141/2011 ELECTION ACT FORMS REGULATION (Consolidated up to 149/2014)
ALBERTA REGULATION 141/2011
Election Act
ELECTION ACT FORMS REGULATION
Election Act forms
1(1) The forms in the Schedule to this Regulation are prescribed for the purposes of the sections of the Election Act indicated on the forms.
(2) The forms required to be prescribed under the Election Act that are not set out in the Schedule are to be prescribed by the Chief Electoral Officer.
Repeal
2 The Election Act Forms Regulation (AR 213/2004) is repealed.
Schedule
Form 1
(Section 39)
Writ of Election
Canada
Province of Alberta
Elizabeth The Second, by the Grace of God, of the United Kingdom, Canada and her other Realms and Territories, Queen, Head of the Commonwealth, Defender of the Faith.
To , Returning Officer of the Electoral Division of .
Greeting:
We command you that, notice of the time and place of election being given, you do cause an election to be held according to law, to elect a Member to serve in the Legislative Assembly of Our Province of Alberta for the Electoral Division of with nomination day for the election to be the day of , 20__, and that in the event of a poll being required you do cause a poll to be taken on the day of , 20 , and you do certify the name of the member so elected to the Chief Electoral Officer on the day of , 20 , being the date fixed for the return of the writ.
Dated at the City of Edmonton in the Province of Alberta, this day of , 20 .
Endorsement
By Order: This writ received on the day of , 20
Chief Electoral Officer Returning Officer
Form 2
(Sections 4(3)(c), 9, 28, 47, 47.1, 71, 73, 75.1, 76, 77.1, 113)
Appointment and Oath of Election Officer
I, (print name) of (print address) , appointed as (position) in the Electoral Division of , Polling Subdivision number (complete if applicable) , in the Province of Alberta, swear (or affirm) that I am legally qualified to act as (position) , that I have not within the immediately preceding 10 years been convicted of an indictable offence where the penalty that may be imposed for that offence is greater than 2 years’ imprisonment and that I will act impartially and diligently in carrying out my duties under the Election Act.
Sworn (or affirmed) before me ) at the of , in the ) Province of Alberta, this day ) of , 20 . ) (signature of election officer)
) (signature of authorized person)
Print name:
Authority to administer oath:
A person who takes a false oath under the Election Act commits an offence and is liable to a fine of not more than $5000 or to imprisonment for not more than 2 years or to both a fine and imprisonment. Form 3
(Sections 59, 60, 61)
Candidate Nomination Paper
We, the undersigned electors, resident in the Electoral Division of , nominate (print name of candidate ) , representing (political party, if applicable) , as a candidate for the election. Printed Name of Elector Residential Address in
Electoral Division Signature of Elector 1 2 3
I, (print name) , swear (or affirm) that I witnessed the signatures of the electors recorded on this Candidate Nomination Paper.
Sworn (or affirmed) before me ) at the of , in the ) Province of Alberta, this day ) of , 20 . ) (signature of witness)
) (signature of authorized person)
Print name:
Authority to administer oath:
A person who takes a false oath under the Election Act commits an offence and is liable to a fine of not more than $5000 or to imprisonment for not more than 2 years or to both a fine and imprisonment.
● Each elector must be ordinarily resident in the named electoral division.
● For verification of residency, the elector’s address should clearly indicate that the elector’s residence is located within the Electoral Division.
● To be signed by 25 or more electors in the presence of the witness.
● Each page containing signatures must be witnessed. Address for Service
Documents may be served and notices given respecting the candidate at:
(address including postal code)
(mailing address including postal code, if the above is not a mailing address)
(telephone number)
(fax number)
Appointment of Official Agent
In accordance with section 60 of the Election Act, I appoint (print name of official agent) of (complete address including postal code ‑ for publication) (telephone number ‑ for publication) (email ‑ not for publication) as my official agent.
I, (print name) , confirm that I am not a candidate and that I consent to my appointment as the official agent.
(signature of official agent) (date)
Declaration of Candidate
I, (print name of candidate) , declare that I am eligible under section 56 of the Election Act to be a candidate, that I consent to my nomination and that I wish my name to appear on the ballot paper as (print any combination of given name, middle name, initials or nickname) (print surname) .
Complete A or B, whichever applies
A The Candidate Nomination Endorsement Certificate from
(political party) confirms that I am the officially endorsed candidate for the Electoral Division of
OR
B I am an independent candidate in the Electoral Division of
I understand that prior to my nomination being accepted, I must be registered with the Office of the Chief Electoral Officer pursuant to section 9 of the Election Finances and Contributions Disclosure Act.
(signature of candidate) (date)
Form 4
(Sections 64, 65(2))
Election Acclamation
I hereby certify that the candidate elected for the Electoral Division of in pursuance of the Writ of Election is (name of candidate) (political party if applicable)
The acclamation is the result of (check one):
□ no other candidates having been nominated
OR
□ the other candidate(s) having withdrawn
(signature of returning officer) (date)
Form 5
(Section 78)
Oath of Interpreter
I, (print name) of (address) appointed as an interpreter in the Electoral Division of for polling station number(s) in the Province of Alberta, swear (or affirm)
● that I will faithfully read or translate such statements, instructions, questions and answers as required at this election,
● that I will not attempt to discover and will, by every means in my power, prevent any other person from finding out how any person is about to vote, or has voted, at this election,
● that I will not communicate to any person any information of any kind that may enable or assist any person to ascertain how any person has voted, and
● that I will, in all respects, maintain and aid in maintaining the absolute secrecy of the voting at this polling place and at this election.
Sworn (or affirmed) before me ) at the of , in the ) Province of Alberta, this day ) of , 20 . ) (signature of interpreter)
) (signature of authorized person)
Print name:
Authority to administer oath:
A person who takes a false oath under the Election Act commits an offence and is liable to a fine of not more than $5000 or to imprisonment for not more than 2 years or to both a fine and imprisonment. Form 6
(Section 82)
Affidavit of Printer
Electoral Division of
I, (print name) , swear (or affirm)
● that by direction of the returning officer for the above named Electoral Division I printed the ballots for use at the election to be held on the day of , 20 on the paper furnished for that purpose,
● that the attached sample shows the description of the ballots printed by me,
● that I supplied the returning officer with (number of ballots) ballots, and
● that no other of the ballots were printed by or supplied by me to anyone.
Sworn (or affirmed) before me ) at the of , in the ) Province of Alberta, this day ) of , 20 . ) (signature of printer)
) (signature of authorized person)
Print name:
Authority to administer oath:
A person who takes a false oath under the Election Act commits an offence and is liable to a fine or imprisonment. Form 7
(Section 83)
Form of Ballot
FRONT OF BALLOT
Stub Counterfoil Ballot CANDIDATE’S NAME NAME OF PARTY OR INDEPENDENT CANDIDATE’S NAME NAME OF PARTY OR INDEPENDENT CANDIDATE’S NAME NAME OF PARTY OR INDEPENDENT CANDIDATE’S NAME NAME OF PARTY OR INDEPENDENT
BACK OF BALLOT 0 0 0 0 0 0 0 0 Stub 0 0 0 0 0 0 0 0 Number from Poll Book Counterfoil INITIALS OF DRO
Electoral Division of
Year
(SECOND FOLD) Ballot (FIRST FOLD) Form 8
(Sections 93, 111(11))
Oath of Secrecy
Electoral Division of
Polling Subdivision Number
I, (print name) , swear (or affirm)
● that I will not communicate to any person any information of any kind that may enable or assist any person to ascertain how any person has voted;
(The following applies to persons referred to in section 92(1) of the Election Act in a polling place during polling hours)
● that I will not attempt to discover and will, by every means in my power, prevent any other person from finding out how any person is about to vote or has voted in this election, except as required under section 96 (voter assistance);
(The following applies to persons referred to in section 111(11) of the Election Act present during the unofficial count)
● that I will not attempt to discover and will, by every means in my power, prevent any other person from finding out how any person has voted in this election.
Sworn (or affirmed) before me ) at the of , in the ) Province of Alberta, this day ) of , 20 . ) (signature of person taking oath)
) (signature of authorized person) (position of person taking oath)
Print name:
Authority to administer oath:
A person who takes a false oath under the Election Act commits an offence and is liable to a fine of not more than $5000 or to imprisonment for not more than 2 years or to both a fine and imprisonment. Form 9
(Sections 95, 99, 104)
Declaration of Elector
Electoral Division of
Polling Subdivision Number
I, (first name) (middle name) (surname)
(date of birth) of (residential address including unit/apartment number) (city/town/village)
(postal code, if applicable) (mailing address-if different from above) (city/town/village) (province) (postal code) (telephone number),
declare that I have not previously voted at this election and that I am a qualified elector by virtue of being
● a Canadian citizen,
● 18 years of age or older,
● ordinarily resident in Alberta for at least the immediately preceding 6 months, and
● ordinarily resident in the polling subdivision in which I wish to vote.
I make this declaration conscientiously believing it to be true and believing that it is of the same force and effect as if made under oath. I am aware that it is an offence to make a false declaration and that I may be liable to a fine of not more than $5000 or to imprisonment for not more than 2 years or to both a fine and imprisonment.
(signature of elector) (date)
Proof of Identity and Residence (check one)
□ Photograph identification issued by a federal, provincial or municipal government in Canada or a government agency containing the elector’s name and current address
OR
□ 2 pieces of identification authorized by the Chief Electoral Officer containing the elector’s name
(the elector’s current address must be contained on at least one of the pieces of identification)
Type of identification:
Type of identification:
OR
□ A declaration has been signed vouching for the elector
Form 10
(Section 95)
Vouching Declaration
Electoral Division of
I, (first name) (middle name) (surname) , declare
● that I personally know the following elector(s) who live(s) at the address(es) indicated:
Print name Print residential address including unit/apartment number
● that I am a qualified elector and my name properly appears on the List of Electors for polling subdivision number _________,
● that I truly believe that the elector(s) named above is (are) ordinarily resident at the address(es) listed above, and
● that I am not a scrutineer for a candidate.
I make this declaration conscientiously believing it to be true and believing that it is of the same force and effect as if made under oath. I am aware that it is an offence to make a false declaration and that I may be liable to a fine of not more than $5000 or to imprisonment for not more than 2 years or to both a fine and imprisonment.
(signature of vouching elector) (date)
TO BE COMPLETED BY THE DEPUTY RETURNING OFFICER OR THE REGISTRATION OFFICER:
□ Name of vouching elector appears on the List of Electors for polling subdivision number .
PROOF OF IDENTITY AND RESIDENCE (Check One)
□ Photograph identification issued by a federal, provincial or municipal government in Canada or a government agency containing the elector’s name and current address
OR
□ 2 pieces of identification authorized by the Chief Electoral Officer containing the elector’s name
(the elector’s current address must be contained on at least one of the pieces of identification)
Type of identification:
Type of identification:
Form 11
(Section 96)
Oath of Inability to Read the Ballot or Physical Incapacity
Electoral Division of
Polling Subdivision Number
I, (print name) , swear (or affirm) that I am unable to read the ballot, or that due to physical incapacity I am unable to mark the ballot.
Sworn (or affirmed) before me ) at the of , in the ) Province of Alberta, this day ) of , 20 . ) (signature or mark of voter)
) (signature of deputy returning officer) A person who takes a false oath under the Election Act commits an offence and is liable to a fine of not more than $5000 or to imprisonment for not more than 2 years or to both a fine and imprisonment. Form 12
(Section 96)
Oath of Friend of Voter
Electoral Division of
Polling Subdivision Number
I, (print name) of (print residential address) , swear (or affirm) that I will mark the ballot in the manner directed by (print name of voter) and I will keep secret how I marked the ballot.
Sworn (or affirmed) before me ) at the of , in the ) Province of Alberta, this day ) of , 20 . ) (signature of friend of voter)
) (signature of deputy returning officer) A person who takes a false oath under the Election Act commits an offence and is liable to a fine of not more than $5000 or to imprisonment for not more than 2 years or to both a fine and imprisonment. Form 13
(Section 108)
Oath of Elector (Alleged Impersonation)
Electoral Division of
Polling Subdivision Number
I, (first name) (middle name) (surname) of (residential address including unit/apartment number) (city/town/village) (postal code, if applicable)
(mailing address-if different from above) (city/town/village) (province) (postal code) (telephone number),
declare that I have not previously voted at this election and that I am a qualified elector by virtue of being
● a Canadian citizen,
● 18 years of age or older,
● ordinarily resident in Alberta for at least the immediately preceding 6 months, and
● ordinarily resident in the polling subdivision in which I wish to vote.
Sworn (or affirmed) before me ) at the of , in the ) Province of Alberta, this day ) of , 20 . ) (signature of elector)
) (signature of authorized person)
Print name:
Authority to administer oath:
A person who takes a false oath under the Election Act commits an offence and is liable to a fine of not more than $5000 or to imprisonment for not more than 2 years or to both a fine and imprisonment.
TO BE COMPLETED BY THE DEPUTY RETURNING OFFICER OR THE REGISTRATION OFFICER:
PROOF OF IDENTITY AND RESIDENCE (Check One)
□ Photograph identification issued by a federal, provincial or municipal government in Canada or a government agency containing the elector’s name and current address
OR
□ 2 pieces of identification authorized by the Chief Electoral Officer containing the elector’s name
(the elector’s current address must be contained on at least one of the pieces of identification)
Type of identification:
Type of identification:
OR
□ A declaration has been signed vouching for the elector
Form 14
(Section 112)
Poll Clerk’s Oath After Conclusion of the Count
I, (print name) , poll clerk for polling station number(s) located at (polling place name) in the Electoral Division of swear (or affirm)
● that the Poll Book for the poll kept under the direction of (print name) , who acted as deputy returning officer was kept correctly by me to the best of my skill and judgment, and
● that the total number of ballots cast according to the Poll Book is and that to the best of my knowledge and belief it contains a true and exact record of the voters who voted at this polling station.
Sworn (or affirmed) before me ) at the of , in the ) Province of Alberta, this day ) of , 20 . ) (signature of poll clerk)
) (signature of deputy returning officer)
Form 15
(Section 112)
Deputy Returning Officer’s Oath After Conclusion of the Count
I, (print name) , deputy returning officer for polling station number located at (polling place name) in the Electoral Division of swear (or affirm) that, to the best of my knowledge and belief,
● the Poll Book kept for the poll under my direction has been kept correctly, and
● the Statement of Poll, List of Electors, Poll Book, envelopes containing ballots and other documents required to be returned by me to the returning officer have been placed in the ballot box.
Sworn (or affirmed) before me ) at the of , in the ) Province of Alberta, this day ) of , 20 . ) (signature of deputy returning
) officer) (signature of authorized person)
Print name:
Authority to administer oath:
Form 16
Election Act
(Sections 111, 116, 118)
Special Ballot Certificate Envelope Elector information: To be completed by the returning officer, election clerk or administrative assistant
Electoral Division of
Polling Subdivision Number
Seq. No. from Special Ballot Poll Book
(first name) (middle name) (surname) of
(residential address) (city/town/village) (postal code, if applicable)
Part 1 To be completed by elector
Step 1 — Required Identification
CHECK: □ I have enclosed a copy of my identification in this envelope. Step 2 — Declaration
I declare that I have not previously voted at this election and that I am a qualified elector by virtue of being
● a Canadian citizen,
● 18 years of age or older,
● ordinarily resident in the Province of Alberta for at least the immediately preceding 6 months, and
● ordinarily resident in the polling subdivision in which I wish to vote.
I declare that I am unable to vote at an advance poll or at the poll on polling day by reason of being
(CHECK ONE)
□ Physically incapacitated
□ Absent from the electoral division
□ An inmate
□ An election officer
□ A candidate, official agent or scrutineer
□ A resident of a remote area
□ Other circumstance (as specified by Chief Electoral Officer) Specify circumstance:
I make the above declarations conscientiously believing them to be true and believing that they are of the same force and effect as if made under oath.
(signature of elector) (date)
Part 2 Special Ballot Checklist To be completed by the returning officer, election clerk or administrative assistant
CHECK A or B, whichever applies
A □ Special Ballot Certificate Envelope has been accepted in accordance with sections 111, 116 and 118 of the Election Act.
OR
B □ Special Ballot Certificate Envelope has not been accepted for one or more of the following reasons (check all that apply):
□ Part 1 is not properly completed,
□ Received after the close of polls on polling day, or
□ Proper identification has not been included.
(signature of returning officer, election (date) clerk or administrative assistant)
Form 17
(Section 118)
Form of Special Ballot
(Front of Ballot)
Print the name of the candidate OR the political party of the candidate on the line below. I vote for:
(Back of Ballot)
SPECIAL BALLOT Supplied by the Chief Electoral Officer of Alberta
Initials of returning officer, election clerk or administrative assistant
Serial No. Form 18
(Section 123)
Mobile Poll Declaration
Electoral Division of
Polling Subdivision Number
I, (print first name, middle name, surname) , declare that I have not previously voted at this election and that I am a qualified elector by virtue of being
● a Canadian citizen,
● 18 years of age or older, and
● ordinarily resident in the Province of Alberta for at least the immediately preceding 6 months.
Complete A or B, whichever applies
A – In‑patient at a Treatment Centre
I am an in‑patient at
(print name of treatment centre)
OR
B – Resident at a Supportive Living Facility
I am ordinarily resident at
(print name of supportive living facility)
I make this declaration conscientiously believing it to be true and believing that it is of the same force and effect as if made under oath.
(signature of elector) (date)
Form 19
(Section 139)
Disclaimer
I, (print name of candidate) , do hereby disclaim my right to become a Member of the Legislative Assembly pursuant to section 139(1) of the Election Act.
(print name of candidate)
(print name of electoral division) (signature of candidate)
(print name of witness)
(print address of witness) (signature of witness)
Filed this day of , 20 .
(signature of Chief Electoral Officer)
Form 20
(Section 142)
Returning Officer’s Affidavit
I, (print name) , Returning Officer for the Electoral Division of swear (or affirm) that on the _____ day of , 20 I submitted the election documents and materials in respect of the election held on the ____ day of , 20 , to the Chief Electoral Officer and that the Statement of Official Results and the Certificate and Return are to the best of my knowledge and belief correct and true.
Sworn (or affirmed) before me ) at the of , in the ) Province of Alberta, this day ) of , 20 . ) (signature of returning officer)
) (signature of authorized person)
Print name:
Authority to administer oath:
Form 21 (Section 186)
Form of Petition Controverted Election
Clerk’s stamp:
COURT FILE NUMBER
COURT OF QUEEN’S BENCH OF ALBERTA
JUDICIAL CENTRE
PETITIONER (Print name of petitioner)
RESPONDENT (Print name of respondent)
DOCUMENT PETITION —
CONTROVERTED ELECTION
ADDRESS FOR SERVICE AND
CONTACT INFORMATION OF
PARTY FILING THIS DOCUMENT
The petition of (print name of petitioner) of (print residential address) shows that
● an election was held on the day of 20 , for the Electoral Division of at which the Respondent was a candidate and has been returned as the person elected at that election,
● the petitioner was a qualified elector at that election (or the petitioner was a defeated candidate at that election), and
● the petition says (state here the facts and grounds on which the petitioner relies).
The petitioner prays that it may be declared that the
election of the Respondent is void and that it be set aside.
Dated this day of , 20 .
(signature of petitioner)
AR 141/2011 Sched.;149/2014
