Note: Please Read Instructions Carefully Before Marking Ballot and Completing Voter's Certificate.
VOTER'S CERTIFICATE
I, ______________, swear or affirm, under penalty of perjury, that I am:
Print Name
In voting, I have marked and sealed my ballot in private and have not allowed any person to observe the marking of the ballot, except for those authorized to assist voters under State or Federal law. I have not been influenced.
My signature and date below indicate when I completed this document.
The information on this form is true and complete to the best of my knowledge. I understand that a material misstatement of fact in completion of this document may constitute grounds for conviction for perjury.
Voter's Signature: _____________________________ Date: / / /
(Month/Day/Year)
Email address: ________________________________ Home Telephone Phone No.:_________________________
Mobile Telephone No.: _____________________________
INSTRUCTIONS
READ THESE INSTRUCTIONS CAREFULLY BEFORE MARKING BALLOT
Fla. Admin. Code Ann. R. 1S-2.030
Rulemaking Authority 20.10(3), 97.012(1), 101.697 FS. Law Implemented 101.62, 101.64, 101.65, 101.6923, 101.697 FS.
New 5-27-02, Amended 11-26-03, 9-13-04. 9-6-07, 7-1-12, 3-20-14, 2-13-20.