Fillable 4-19f Shell for Forms Sheet

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4-19f Shell for Forms Sheet

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AW4-19
Prescribed by Secretary of State
Section 34.001, Texas Election Code
03/07
REQUEST FOR INSPECTORS
To the Secretary of State:
We, the 15 undersigned registered voters of the County/Political Subdivision of ________________
_____________________ hereby petition the Secretary of State to appoint an inspector for the
_________________________________ to be held on _______________ using __________________________.
(name of election) (date of election) (type of voting device)
We understand that this petition is due in the Secretary of State's Office not later than 4 regular business days before
the election. (Please submit petition as soon as possible so an inspector can be appointed in a timely manner.)
Signature Voter RegistrationVUID No. Signature Voter Registration VUID. No.
_________________________________________ ______________________________________
_________________________________________ ______________________________________
_________________________________________ ______________________________________
_________________________________________ ______________________________________
_________________________________________ ______________________________________
_________________________________________ ______________________________________
_________________________________________ ______________________________________
_________________________________________ ______________________________________
ADDITIONAL INFORMATION: (It is very important that petitioner provide the information required below.
Please make sure that all information is correct.)
We request inspection of the following precinct(s) where the problems listed below are anticipated:
Precinct Number Physical Address Problem(s)
______________________________________________________________________________________
If additional information is needed, the Secretary of State can contact:
_________________________________________ ____________________________________(W)
Name of person submitting petition Telephone number
_________________________________________ ____________________________________(H)
Address Telephone number
_________________________________________
City, State, Zip Code
AW4-19
Prescribed by Secretary of State
Section 34.001, Texas Election Code
3-07
PETICION PARA INSPECTORES
Al Secretario de Estado:
Nosotros, los quince infrascritos ciudadanos siendo residentes del Condado/Subdivisión Política de
______________________ por la presente pedimos que el Secretario de Estado nombre un inspector para la
_______________________ que se celebrará el _____________ en la cual se usará ____________________.
(nombre de elección) (fecha de elección)
(modo de votar)
Nosotros entendemos que esta petición deberá registrarse en la oficina del Secretario de Estado a lo menos 4 días
laborales regulares antes de la elección. (Favor de presentar la petición a la oficina del Secretario de Estado lo
mas pronto posible para poder designar al inspector de una manera oportuna.)
Firma Núm. de VUID de Registro Firma Núm. de VUID de Registro
_________________________________________ ______________________________________
_________________________________________ ______________________________________
_________________________________________ ______________________________________
_________________________________________ ______________________________________
_________________________________________ ______________________________________
_________________________________________ ______________________________________
_________________________________________ ______________________________________
_________________________________________ ______________________________________
__________________________________________________________________________________________
INFORMACION ADICIONAL: (Es importante que la persona presentando la petición incluya toda la información
abajo solicitada. Favor de verificar que la información este correcta.)
Solicitamos inspección de los siguientes precintos donde anticipamos los problemas registrados aquí abajo:
Número de Precinto Dirección Problema(s)
__________________________________________________________________________________________
Si se necesita más información, el Secretario de Estado se comunicará con la siguiente persona.
_________________________________________ ______________________________________
Nombre de la persona que presenta la petición
Número de teléfono (en el trabajo)
_________________________________________ ______________________________________
Domicilio: Calle y Número Número de teléfono (en casa)
_________________________________________
Ciudad, Estado, Zona Postal
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4-19f Shell for Forms Sheet

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Completed 2 July 2020

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