Item_#13_artwork.pdf

Verifi ed by

GIS

/ Out of County

Address Issue Signature Issue

Not in Jurisdiction Not Registered Ballot missing from Envelope

County:Status:Date:

Voted In-Person:

VBM Returned:

Not Counted

XS MRMA MA NA BResidential Address:

Residence Ballot Type

Residence Precinct

Ballot Type

Envelope Precinct EL

Counted

/VERIFIED BY:

FOR OFFICE USE ONLY

ocvote.gov/plookup P-Lookup Check box if P-Lookup is used

Use the Precinct Lookup Tool (P-Lookup) if the residential address is not found in the ePollbook. Any problems please call the help desk.

Voter completed Section 1 - Qualifi cations Voter signed and dated Section 2 Voter provided an Orange County home address (If not found use P-Lookup. See below for instructions.)

Front of the envelope matches the Ballot Receipt Label Voter completed required sections 1 - 6

Reason for incomplete voter section, if any:

Vote Center Staff Check List (Presidential Primary Election only)

Precinct Number:

Political Party:

Ballot Issued

Name of CSR assisting voter:

Place Ballot Receipt Label Here

Voter needs to register to vote in Orange County

Orange County address not found in ePollbook (P-Lookup used)

Voter record states “Already Voted” or “VBM Returned”

Other:

Reason Provisional Ballot was issued:

Date:

Time:

Vote Center ID:

If receipt does not print, write in below:

Place Ballot Receipt Label Here

Verifi ed by

GIS

/ Out of County

Address Issue Signature Issue

Not in Jurisdiction Not Registered Ballot missing from Envelope

County:Status:Date:

Voted In-Person:

VBM Returned:

Not Counted

XS MRMA MA NA BResidential Address:

Residence Ballot Type

Residence Precinct

Ballot Type

Envelope Precinct EL

Counted

/VERIFIED BY:

FOR OFFICE USE ONLY

ocvote.gov/plookup P-Lookup Check box if P-Lookup is used

Use the Precinct Lookup Tool (P-Lookup) if the residential address is not found in the ePollbook. Any problems please call the help desk.

Voter completed Section 1 - Qualifi cations Voter signed and dated Section 2 Voter provided an Orange County home address (If not found use P-Lookup. See below for instructions.)

Front of the envelope matches the Ballot Receipt Label Voter completed required sections 1 - 6

Reason for incomplete voter section, if any:

Vote Center Staff Check List (Presidential Primary Election only)

Precinct Number:

Political Party:

Ballot Issued

Name of CSR assisting voter:

Place Ballot Receipt Label Here

Voter needs to register to vote in Orange County

Orange County address not found in ePollbook (P-Lookup used)

Voter record states “Already Voted” or “VBM Returned”

Other:

Reason Provisional Ballot was issued:

Date:

Time:

Vote Center ID:

If receipt does not print, write in below:

Place Ballot Receipt Label Here

1-888-628-6837 by calling ocvote.gov/provisional by visiting

Affi davit #

30AC330001

Affi davit #

30AC330001

Check the status of your Provisional Ballot

Please Detach and Give to VoterVOTER RECEIPT VOTER RECEIPT

• California Elections Code § 14310 (c)(2) states that provisional ballots are counted only after establishing the voter’s right to vote by order of a superior court, which must be received prior to the completion of the offi cial canvass.

You are a Conditional Voter Registration provisional voter because:

You registered to vote after the 15 day close of registration. If you need further assistance please ask staff . California Elections Code § 2170(d)(3) states that the elections offi cial shall conduct the receipt and handling of each conditional voter registration and off er and receive a corresponding ballot in a manner that protects the secrecy of the ballot and allows the elections offi cial to process the registration, determine the registrant’s eligibility to register, and validate the registrant’s information before counting or rejecting the corresponding ballot.

Affi davit #:30AC330001

1-888-628-6837 by calling ocvote.gov/provisional by visiting

Affi davit #

30AC330001

Affi davit #

30AC330001

Check the status of your Provisional Ballot

Please Detach and Give to VoterVOTER RECEIPT VOTER RECEIPT

• California Elections Code § 14310 (c)(2) states that provisional ballots are counted only after establishing the voter’s right to vote by order of a superior court, which must be received prior to the completion of the offi cial canvass.

You are a Conditional Voter Registration provisional voter because:

You registered to vote after the 15 day close of registration. If you need further assistance please ask staff . California Elections Code § 2170(d)(3) states that the elections offi cial shall conduct the receipt and handling of each conditional voter registration and off er and receive a corresponding ballot in a manner that protects the secrecy of the ballot and allows the elections offi cial to process the registration, determine the registrant’s eligibility to register, and validate the registrant’s information before counting or rejecting the corresponding ballot.

Affi davit #:30AC330001

ZipStateCityPrevious Home Address (No PO Box), Apt/Unit/Spc #

Online Registration Confi rmation #Previous Name

REGISTRATION HISTORY ( If you were previously registered or pre-registered to vote, complete this section )

EmailPhone Number

CONTACT INFORMATION ( Optional )

(If no language preference is chosen, election materials will be sent in English)

Other: English Chinese 中文中文

Korean 한국어

Spanish Español

Vietnamese Tiếng Việt

My language preference for receiving election materials is:

LANGUAGE PREFERENCE

(If you choose “No Party/None”, you may not be able to vote for some parties’ candidates at a primary election for U.S. President, or for a party’s central committee.)

No Party / None

Other (specify):

American Independent Party Libertarian Party Democratic Party Peace and Freedom Party Green Party Republican Party

I do not want to choose a political party preference:I want to choose a political party preference:

POLITICAL PARTY PREFERENCE

ZipStateCityMailing Address or PO Box

ADDRESS WHERE YOU RECEIVE MAIL ( if different than above ) ZipStateCityHome Address, Apt/Unit/Spc #

CURRENT HOME ADDRESS IN ORANGE COUNTY ( No PO Box, Mail Box, Virtual Mail Box, Government / Public Building )

Social Security # (Last 4 digits) :CA Driver’s License or CA State ID # :

U.S. State or foreign country of birth :

Month Day Year

/ /Birth Date MM/DD/YYYY :

IDENTIFICATION

Middle Name Last NameFirst Name

LEGAL NAME

Month Day Year

SIGNATURE (Required)

I swear or affi rm that:

I am a U.S. citizen and a resident of California and at least 18 years old. I am not currently serving a state or federal prison term for the conviction of a felony. I am not currently found mentally incompetent to vote by a court. I understand that it is a crime to intentionally provide incorrect information on this form. I declare under penalty of perjury under the laws of State of California that the information on this form is true and correct.

AFFIDAVIT

Yes No ... I am a U.S. citizen and resident of Orange County, California.

Yes No ... I am 18 years of age or older.

QUALIFICATIONS

Affi davit #

VOTER: Complete Sections 1 - 9 (Please PRINT clearly)

VOTING TWICE IN THE SAME ELECTION IS A FELONYVOTING TWICE IN THE SAME ELECTION IS A FELONY

Orange County Provisional Ballot Envelope Conditional Voter Registration (CVR) 30AC330001