Form Ds De 49-Os/ts - Provisional Ballot Voter'S Certificate And Affirmation - Provisional Ballot Processing Procedures (2006)
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ROVISIONAL
ALLOT
OTER
S
ERTIFICATE AND
FFIRMATION
(Section 101.048(3) and 101.049, Florida Statutes)
Your Ballot WILL NOT COUNT IF YOU DO NOT VOTE in the correct precinct
:
Procedures for Touch Screen Voter to Follow:
Procedures for Optical Scan Voter to Follow
1. In front of the election official, complete and sign this
1. In front of the election official, complete and sign this
Provisional Ballot Voter’s Certificate and Affirmation.
Provisional Ballot Voter’s Certificate and Affirmation.
2. Give the certificate to the election official to witness
2. Give the Certificate to the election official to witness
and obtain your Notice for Provisional Ballot Voter.
and obtain your Notice for Provisional Ballot Voter.
3. Vote your provisional ballot in secret using the voting
3. Vote your provisional ballot in secret.
system at your precinct or early voting site.
4. After voting, put ballot into secrecy envelope and put
secrecy envelope into provisional ballot envelope.
5. Seal the provisional ballot envelope.
6.
Place the provisional ballot envelope in the
appropriate ballot box.
State of Florida
County of ___________
I do solemnly swear (or affirm) that my name is _______________________________; that my date of birth is
(First)
Middle)
(Last)
______________ ; that I am registered and qualified to vote in __________ County, Florida; that I am registered
(Month/Day/Year)
in the _________________ Party; that I am a qualified voter of the county; and that I have not voted in this election.
I understand that if I commit any fraud in connection with voting, vote a fraudulent ballot, or vote more than once in an
election, I can be convicted of a felony of the third degree and fined up to $5,000 and/or imprisoned for up to 5 years.
X
Signature of Voter
_________________________________________________________________________
Previous name (if changed) ____________________________________________________________________
Current Residence Address ____________________________________________________________________
Current Mailing Address, if different______________________________________________________________
City, State, Zip Code__________________________________________________________________________
FL Driver’s License Number, FL ID number, or last four digits of SSN ___________________________________
(A voter’s Fl DL# , Fl ID card # and social security number are confidential and exempt from public access under s. 97.0585, Florida Statutes)
Day Time Phone Number: (optional) _____________________________________________________________
Voter Comments (Including date and place where you registered, if known, responses to challenge, or other
information): ________________________________________________________________________________
___________________________________________________________________________________________
Witness of Election Official (Must be completed by Election Official)
Provisional Ballot ID Number (Touch screen only) _____________
_
Election Date: ________________
Precinct ___________
Ballot Style _________________
Sworn to and subscribed before me this _______ day of __________________________, 20 _____
X_________________________________________________________________
Election Official
DS DE #49-OS/TS (eff. 01/06)
(front)
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