OFFICIAL LETTERHEAD OF THE PROVINCIAL LEGISLATURE

To: [The Chairperson of the NCOP or a person designated by the Chairperson of the NCOP]

Name of Bill:__________________________________________________

Number of Bill:_________________________________________________

Date of deliberation:_____________________________________________

Vote of legislature:_______________________________________________

[Indicate whether the provincial legislature votes in favour, against or abstains from voting on the Bill]

Signature:______________________

Date:______________________

[Signature of the Speaker or person designated by the Speaker to preside in House on Bill]