| Surname and names | Office |
|---|---|
| Goyke Alicja Maria | Chair |
| Mielewczyk Renata Katarzyna | Vicechair |
| Ruszewski Michał Grzegorz | Member |
| Szymański Mariusz Franciszek | Member |
| Wendt Władysław Leon | Member |
| 1. | Number of voters entitled to vote (included in the roll of voters with additional forms) | 42 |
| 1a. | including those in part A of the roll of voters (Polish citizens) | 42 |
| 1b. | including those in part B of the roll of voters (citizens of the European Union who are not citizens of Poland) | 0 |
| 2. | Commission received ballot papers | 41 |
| 3. | Unused ballot papers | 24 |
| 4. | Number of voters to whom ballot papers were delivered | 17 |
| 4a. | including those in part A of the roll of voters (Polish citizens) | 17 |
| 4b. | including those in part B of the roll of voters (citizens of the European Union who are not citizens of Poland) | 0 |
| 5. | Number of voters voting by proxy (number of ballot papers issued on the basis of received acts power of attorney) | 0 |
| 6. | Number of voters to whom election packages were sent | 0 |
| 7. | Number of return envelopes received | 0 |
| 7a. | Number of return envelopes without the statement on personal and secret vote | 0 |
| 7b. | Number of return envelopes in which the statement was not signed by the voter | 0 |
| 7c. | Number of return envelopes without the envelope for the ballot paper | 0 |
| 7d. | Number of return envelopes in which envelope for ballot paper was not sealed | 0 |
| 7e. | Number of envelopes for ballot papers put into ballot box | 0 |
| 8. | Number of ballot papers taken out of the ballot box | 17 |
| 8a. | including the number of ballot papers taken out of envelopes | 0 |
| 9. | Number of invalid ballot papers (other than those officially provided or those not stamped with the district electoral commission's seal) | 0 |
| 10. | Number of valid ballot papers | 17 |
| 11. | Number of invalid votes (out of valid ballot papers) | 1 |
| 11a. | including those with mark „X” put next to two or more candidates | 0 |
| 11b. | including those without any mark „X” | 1 |
| 12. | Number of votes validly cast for all candidates (out of valid ballot papers) | 16 |
| Number | Surname and names | Committee | Number of votes |
|---|---|---|---|
| 1 | STYN Andrzej | KOMITET WYBORCZY WYBORCÓW DOBRA GMINA | 0000000009 9 |
| 2 | ŚLIWICKI Adam | KOMITET WYBORCZY WYBORCÓW ADAMA ŚLIWICKIEGO | 0000000007 7 |