Registration Form For Third Party Voter Registration
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1
2SUPERVISORS OF ELECTIONS’ ACCOUNTING OF
THIRD-PARTY VOTER REGISTRATION ORGANIZATION’S
VOTER REGISTRATION APPLICATIONS
Page ___ of ___ pages.
(S
97.0575, F
S
)
ECTION
LORIDA
TATUTES
Supervisors of Elections must account for voter registration applications provided to, and
received from, each third-party voter registration organization.
This report reflects applications provided/received on:
_________________, _____, 20____.
(month)
(day)
(yr)
NOTES:
(1) If forms are received from someone who should be registered as a third-party voter registration organization
but is not registered, submit the requested information and place “NR” in the “3P _____” line. Obtain as much
identifying information about the unregistered person or organization as possible. Inform the person or entity
of the requirement to register and report the incident and information to the Division of Elections.
(2) Supervisors of Elections are to submit this completed form either as a pdf attachment in an email to
3PVRO@dos.state.fl.us or transmit the form to the Division of Election’s facsimile machine at 850-245-6291
no later than noon on the business day following the day being reported.
3P__________
Third-party organization voter registration organization’s identification number:
a. Number of voter registration applications provided:
State forms: _____________
Federal forms: _________________
b. Number of voter registration applications received:
State forms (blank):
_______
State forms (non-blank):
_________
Federal forms (blank): _______
Federal forms (non-blank): _________
3P__________
Third-party organization voter registration organization’s identification number:
a. Number of voter registration applications provided:
State forms: _____________
Federal forms: _________________
b. Number of voter registration applications received:
State forms (blank):
_______
State forms (non-blank):
_________
Federal forms (blank): _______
Federal forms (non-blank): _________
3P__________
Third-party organization voter registration organization’s identification number:
a. Number of voter registration applications provided:
State forms: _____________
Federal forms: _________________
b. Number of voter registration applications received:
State forms (blank):
_______
State forms (non-blank):
_________
Federal forms (blank): _______
Federal forms (non-blank): _________
Use continuation pages if needed – see next page.
Supervisor of Elections Office for:
____________________________ County
_________________________________________
___________________________
_______________
Name of Person Completing Form
Signature
Date Submitted
DS-DE 124 (eff. 06/2011)
Rule 1S-2.042, F.A.C.
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