Scheduling Order Page 5
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11Certification of Authorized Representative
I hereby agree to serve as the authorized representative for
_
(Name of Voter)
for purposes of obtaining an emergency absentee ballot for the above voter only and to
return the ballot, after it has been completed by the voter
and
sealed in the required
envelope to the County Board of Elections. I certify that! am not acting as the authorized
representative during t-his election for a..-1Y person who does not live in the same
household as the above-named voter.
(Signature ofAuthorized Representative)
Name and Address of Authorized Representative (Please Print):
(Name ofAuthorized Representative)
(Address ofAuthorizedRepresentative)
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