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Receipt for challenge fee Book No …………… Page Receipt for challenge fee Book No ………….

Page
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.

Received a sum of Rs.2 ( Rupees two only ) in cash


fro Sri ……………………………….( Candidate/ Election Agent Date ……………………..
Polling Agent on account of deposit for challenge under rule
36 of the Conduct of Election Rules 1961.
Presiding officer for Polling Station No………………….of
…………………………………………………………………………………………………
Date…………………….. ……………………………

Presiding Officer Legislative Council Constituency comprised within the


……………………………………….Council Constituency.
Forfeited to Government

Presiding Officer,

Received back the amount of Rs.2 ( Rupees two only)


under rule 36(5) of the Conduct of Election Rules. 1961

Name and Signature of Candidate/ Election Agent /


Polling Agent.

Date ……………………

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