Form 3 (9502P) "Appointment for Voting Proxy" - Ontario, Canada

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Appointment for Voting Proxy – Form 3
Ministry of Municipal Affairs
and Housing
Municipal Elections Act, 1996 (Section 44)
Instructions
Complete two copies of this form.
Person Appointing a Proxy
1. You must be eligible to vote in the municipality.
2. The person you are appointing must be eligible to vote in the municipality.
3. You must know the person who you are appointing and be able to fill in their information.
To complete the form:
1. Provide your information in Box A.
2. Provide the information of the person you are appointing in Box B.
3. Sign and date the form in Box C.
Note: You must fill in the information of the person you are appointing before signing the form in Box C.
After completing two copies of the form, give them to the person who you are appointing as your proxy.
This form is a public record and the copy on file with the clerk may be inspected by any person.
Person Being Appointed
1. You must be eligible to vote in the municipality.
2. You may be appointed as the proxy of one or more family members (parent, grandparent, child, grandchild,
sibling or spouse) or as the proxy of one person who is not a family member.
To certify the appointment:
Once the person appointing you has given you two copies of the completed form, take them to the municipal clerk
(or a person designated by the municipal clerk).
You can present the two copies of the form at the clerk’s office (or another location designated by the clerk) during
normal office hours, or during the hours of 12 p.m. to 5 p.m. on any day of an advance vote.
The clerk may require you to provide proof of identity or eligibility to vote before certifying the proxy.
You must sign the form in Box D in front of the clerk.
After certifying the proxy (Box E), the clerk will keep one copy of the form and give the other copy back to you.
This form is a public record and the copy on file with the clerk may be inspected by any person.
To vote as a proxy:
Take the completed and certified form to the voting place.
When you present the form, you will be required to take the oath in Box F.
After taking the oath, you can vote on behalf of the person who appointed you.
9502P_E (2022/04)
© Queen's Printer for Ontario, 2022
Disponible en français
Appointment for Voting Proxy – Form 3
Ministry of Municipal Affairs
and Housing
Municipal Elections Act, 1996 (Section 44)
Instructions
Complete two copies of this form.
Person Appointing a Proxy
1. You must be eligible to vote in the municipality.
2. The person you are appointing must be eligible to vote in the municipality.
3. You must know the person who you are appointing and be able to fill in their information.
To complete the form:
1. Provide your information in Box A.
2. Provide the information of the person you are appointing in Box B.
3. Sign and date the form in Box C.
Note: You must fill in the information of the person you are appointing before signing the form in Box C.
After completing two copies of the form, give them to the person who you are appointing as your proxy.
This form is a public record and the copy on file with the clerk may be inspected by any person.
Person Being Appointed
1. You must be eligible to vote in the municipality.
2. You may be appointed as the proxy of one or more family members (parent, grandparent, child, grandchild,
sibling or spouse) or as the proxy of one person who is not a family member.
To certify the appointment:
Once the person appointing you has given you two copies of the completed form, take them to the municipal clerk
(or a person designated by the municipal clerk).
You can present the two copies of the form at the clerk’s office (or another location designated by the clerk) during
normal office hours, or during the hours of 12 p.m. to 5 p.m. on any day of an advance vote.
The clerk may require you to provide proof of identity or eligibility to vote before certifying the proxy.
You must sign the form in Box D in front of the clerk.
After certifying the proxy (Box E), the clerk will keep one copy of the form and give the other copy back to you.
This form is a public record and the copy on file with the clerk may be inspected by any person.
To vote as a proxy:
Take the completed and certified form to the voting place.
When you present the form, you will be required to take the oath in Box F.
After taking the oath, you can vote on behalf of the person who appointed you.
9502P_E (2022/04)
© Queen's Printer for Ontario, 2022
Disponible en français
Appointment for Voting Proxy – Form 3
Ministry of Municipal Affairs
and Housing
Municipal Elections Act, 1996 (Section 44)
For Office Use (Initial after voters' list
Box A: Elector Making Appointment
has been checked)
Municipality
Ward Name or Number (if any)
Voting Subdivision Number (if known)
Elector Making Appointment
Last Name or Single Name
Given Name(s)
Full address within this municipality
Suite/Unit Number Street Number
Street Name
Municipality
Province
Postal Code
For Office Use (initial after voters' list
Box B: Elector Appointed
has been checked)
Municipality
Ward Name or Number (if any)
Voting Subdivision Number (if known)
Elector Appointed
Last Name or Single Name
Given Name(s)
Full address within this municipality
Suite/Unit Number Street Number
Street Name
Municipality
Province
Postal Code
Relationship of Elector Appointed to Elector Making the Appointment (check one only)
Related (parent, grandparent, child, grandchild, sibling or spouse)
Not related
Box C: Statement of Elector Making Appointment
I, the undersigned, a qualified elector in the above municipality, do hereby appoint
(person named in Box B), to vote on my behalf and, if related, do attest to their relationship to me.
Signature of the Elector Making Appointment
Date (yyyy/mm/dd)
Note: It is unlawful to sign this proxy form until Box B is completed.
The name of the elector appointed must be filled in at the time the elector making the appointment signs the statement.
9502P_E (2022/04)
© Queen's Printer for Ontario, 2022
Disponible en français
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Box D: Declaration By Elector Appointed (to be completed in the presence of the clerk or designate
at the clerk’s office or other designated location)
I, the undersigned, a qualified elector in the above municipality, affirm that I have been appointed to vote in good faith and
have been instructed to do so on behalf of the elector who made the appointment and that I have not been previously
}
appointed to vote on behalf of any other non-related person.
Declared before Clerk or Commissioner
in the
on (yyyy/mm/dd)
Signature of Clerk or Commissioner, etc.
Signature of Elector Appointed
Box E: Certification by Clerk
I hereby certify that the elector making the appointment is qualified to vote in this municipality and that the elector appointed is a
qualified elector in this municipality and is authorized to vote on behalf of the elector making the appointment.
Signature of Clerk or Designate
Date of Certification (yyyy/mm/dd)
Note: Clerk may require proof of identity of elector appointed before certifying proxy. This form is a public record and the copy
on file with the clerk may be inspected by any person.
Box F: Oral Oath
I swear or solemnly affirm:
that I am the elector appointed; and
that I am voting in good faith on behalf of the elector who made the appointment; and
I have not been previously appointed to vote on behalf of any other non-related person.
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9502P_E (2022/04)
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