SCHEDULE 4FORM OF POSTAL VOTING STATEMENT REFERRED TO IN PARAGRAPH 22 OF SCHEDULE 2

POSTAL VOTING STATEMENT FOR A POSTAL VOTE AT PARLIAMENTARY OR EUROPEAN PARLIAMENTARY ELECTION WHICH IS TAKEN WITH THE LOCAL GOVERNMENT ELECTION AND THE PROCEEDINGS ON THE ISSUE AND RECEIPT OF POSTAL BALLOT PAPERS IN RESPECT OF EACH ELECTION ARE TAKEN TOGETHER

3.  Do not put any other marks on the ballot paper. If you do, your vote might not be counted.