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<br />AFFIRMATION <br />Under penalty for false swearing. I swear (or affirm) that my name is: <br /> <br />... <br /> <br />t <br /> <br />(Middle Name! InitiaD <br /> <br />~~cl ~Nam~ <br />My current address of legal residence is: <br /> <br />(Street Address) <br /> <br />(0C;y) <br /> <br />(l1p COdel <br /> <br />(Voter Registration No. (Part;)' AffiUation) treJephone. OptionaD <br />or Date of Birth) <br /> <br />~~~l~~~m:lil~~._:i@,~~~~- <br /> <br />NO~LUQmuD NO~LUQ~ <br /> <br />Complete when eJectOr is In the precinct <br />register, but has no identification OR when <br />eJectOrs signature differs trom that on Ills <br />Identification. <br /> <br />(Date of Birth) <br /> <br />(Print Fonner Namel <br /> <br />, NO ~L UQUlRED CAU UQUIRED <br />. I <br />EjectOr has current voters m card EJectOr has no current voter"S m card <br />and or <br />current residence on Precinct Map current address or legal residence Is not on Map <br />Authorization No. <br />Precinct Number 0 Eligible EJeaorlPrednct No. <br />o Name is In Precinct Register <br />D Name is in Precinct R~ 0 Add Name to Precinct Register <br />o Add name to Precinct R~ 0 Not EligIble to Vote <br /> <br />1i~~a~~~~r~_,::::M <br /> <br /> <br />AuttloJi%at1on No. <br /> <br />CALL UQU'IRID <br />o Eligfble EJec:tOr/Prednct No. 0 Not EligIble to vote <br />o .Add Name to Precinct Register <br /> <br />I furcher swear (or aftirm> d1at I am a quaMed <br />elector In Dade Coun~, Florida. and have DOt <br />voted In lhis eIecCIon. <br /> <br /> <br />~igna.tureor~ofElec:tor) <br />DICe <br /> <br />(: <br /> <br /> <br />I Please CO to: <br />, (Precinct I) <br /> <br />Signature of Oerk or DepUt;y aerk <br /> <br />I <br /> <br />PrednctNumber. <br /> <br />(Address) <br /> <br />I <br /> <br />(Name of polling Place) <br />