Fillable OPTICAL SCAN/TOUCH SCREEN PROVISIONAL BALLOT VOTERS CERTIFICATE AND (Florida Division of Corporations)

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OPTICAL SCAN/TOUCH SCREEN PROVISIONAL BALLOT VOTERS CERTIFICATE AND (Florida Division of Corporations)

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DS DE #49 OS/TS (eff. 01/06)
(front)
OPTICAL SCAN/TOUCH SCREEN
PROVISIONAL BALLOT VOTER’S CERTIFICATE AND AFFIRMATION
(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 Optical Scan Voter to Follow:
1. In front of the election official, complete and sign this
Provisional Ballot Voter’s Certificate and Affirmation.
2. Give the Certificate to the election official to witness
and obtain your Notice for Provisional Ballot Voter.
3. Vote your provisional ballot in secret.
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.
Procedures for Touch Screen Voter to Follow:
1. In front of the election official, complete and sign this
Provisional Ballot Voter’s Certificate and Affirmation.
2. Give the certificate to the election official to witness
and obtain your Notice for Provisional Ballot Voter.
3. Vote your provisional ballot in secret using the voting
system at your precinct or early voting site.
State of Florida
Coun
ty 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.
Signature of Voter
X_________________________________________________________________________
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
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DS-DE #49 OS/TS (eff. 01/06) (back)
OPTICAL SCAN/TOUCH SCREEN
PROVISIONAL BALLOT PROCESSING PROCEDURES
FOR SUPERVISOR OF ELECTIONS AND
CANVASSING BOARD USE ONLY
CANVASSING BOARD
ACTION
STATE REASON IF REJECTED
COUNTED
NOT COUNTED
Information Verified At Supervisor’s Office
Registered? Yes______ No______ Status ____________
FVRS Voter ID Number ____________________
Address (if different )_________________________________
Voted in Correct Precinct? Yes______ No______
Voter Cast Absentee Ballot? Yes______No______
Voted During Early Voting? Yes______No______
Signature Match? Yes______No______ (Attach copy)
Investigative Findings:
_________________________________________________
_________________________________________________
_________________________________________________
Reason for Provisional Ballot (Check all that apply)
Voter’s name does not appear on the precinct register and voter’s eligibility cannot
be verified.
Voter refutes the supervisor’s office confirmation that he or she is not
registered/eligible.
There is an indication on the precinct register that the voter has requested an
absentee ballot and the voter does not have a ballot to surrender. Poll worker
cannot verify that the voter has not voted.
There is an indication on the precinct register that the voter has returned the
absentee ballot or has voted in the office or at an early voting site, but the voter
maintains that he or she has not voted, even after a call to the office.
Voter did not provide picture/signature identification.
There is an indication on the precinct register that the voter has been challenged in
this election.
Voter is challenged at the precinct (Attach copy of challenge).
Voter’s ID signature and signature given do not match. Voter refused affidavit.
Indication on precinct register that voter’s Fl DL #, Fl ID card # or SSN is not yet
verified by the Department of State in conjunction with DHSMV.
Other (provide comment) ______________________________________
Extended Hours Only:
Vote cast after 7 p.m. due to extended hours at polls by:
Qualified voter
Eligibility undetermined
Procedures for Election Official to Follow:
1. Check reason(s) for provisional ballot in box below.
2. Have the voter complete the Provisional Ballot Voter’s Certificate and Affirmation.
3. Witness the voter’s signature and complete the “Election Official” section of the Certificate.
4. Issue the Notice for Provisional Ballot Voter to the voter.
5. Optical scan voters only:
a. Issue the voter a provisional ballot, secrecy envelope, and this Certificate envelope.
b. Instruct voter to place provisional ballot envelope in ballot box after voting.
6. Touch screen voters only:
a. Assign unique ballot identifier and write number in the “Election Official” section of the
Certificate.
b.
Activate the provisional ballot.
Procedures for Canvassing Board to Follow:
1. Review information provided in the Voter’s Certificate and Affirmation.
2. Determine if voter is registered in state FVRS.
3. Determine if voter voted in the correct precinct.
4. Match voter’s signature with signature on file.
5. Determine whether voter cast an absentee ballot or voted during early
voting.
6. Review all information provided by supervisor’s office, evidence
provided by voter, if any, and any evidence provided by challenger, if
applicable.
7. Accept or reject provisional ballot based on preponderance of the
evidence.
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OPTICAL SCANTOUCH SCREEN PROVISIONAL BALLOT VOTERS CERTIFICATE AND (Florida Division of Corporations)

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Completed 30 July 2020

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