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No…………… No……………….
Office of the Presiding Officer for Polling Station No……………. Received a sum of Rs.2 ( Rupees two only) in cash from Sri
of …………………………………… Legislative Council Constituency …………………………. Candidate / Election Agent
comprised within ………………. Council Constituency. ……………………… / Polling on account of deposit for challenge
under rule 36 of the Conduct of Election Rules 1961.
Presiding Officer,
Date ……………………