New Zealand: Acts affecting Native Lands, 1886, 1888-91 and 1894-95

[or

[ or,

The total number of voters whose votes were recorded was; and, as none of the proposals respecting licenses in the district [ unclear: cotained] the prescribed majority, I declare none of them to be carried.]

Dated at, this day of, 18

Returning Officer.

Note.—All the forms in this schedule are to be altered to sit the circumstances.