You are required to indicate which of the following options applies to you:

OPTION 1

At the above election I voted as a (tick the appropriate box): Postal Voter         or Ordinary Voter         or Absent Voter Name and location of polling place at which you voted (if appropriate): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

OPTION 2

I failed to vote because: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

If your reason(s) for failing to vote are considered to be valid and sufficient, no further action will be taken.

If your reason(s) are not considered to be valid and sufficient, indicate (by ticking one of the following boxes) your choice:

having a penalty of $40.00 imposed on you by the Electoral Commissioner

having the matter dealt with in a Magistrate's Court. If Court proceedings are taken, you may have to pay both a fine and Court costs

  *...................................         ......................
       (Signature of elector)                    (Date)

* Note: If the elector is unable to complete, sign and post this notice within the time specified, another elector who has personal knowledge of the facts may complete, sign and post it within that time.

This notice must be completed, inserted in the enclosed envelope and posted to the Victorian Electoral Commission within 21 days of the date below.

Date of Notice: 9/8/96

[signed]
Electoral Commissioner