This is a sample statement of the vote for local special ballots, which is completed at the verification and at the count for the electoral district. It first lists the number of returned outer envelopes, spoiled envelopes and loose ballots found in the ballot box, and total valid outer envelopes. It then lists the number of votes cast for each candidate, total valid votes, rejected ballots during the count and votes cast. It captures the ballot box seal numbers and must be signed by the primary team of deputy returning officer and poll clerk. It may be signed by candidates’ representatives.