Prescribed by Secretary of State
Section 127.156, 65.013, Texas Election Code
Election Title: _____________________________ Location Name:___________________________________
Date:______________ Ballot Scanner Identification Number(s): __________________ __________________
INSTRUCTIONS: This is the most important form completed by the ELECTION JUDGE!
Please fill in each of the lines below and sign the form. Direct each clerk and up to two poll watchers (if present)
to sign the form. File each copy of this form in the appropriate locations as directed below.
Initial Ballots Supplemental Ballots
Issued Issued
A. Number of Blank Ballots Received
Public Count of voted ballots from Ballot Scanner Results
Number of voted Provisional Ballots
The number of voted Provisional Ballots sealed in Affidavit
Envelopes. This number should match the total number of
names on the List of Provisional Voters.
D. Number of Spoiled Ballots + Number of Thrown Out
Ballots + Unused blank ballots signed by the Election
The number of ballots recorded on the “Register of Spoiled
Ballots” form and placed in “Envelope for Spoiled Ballots” + the
number of Thrown Out Ballots that were placed in the
“Envelope for Thrown Out Ballots” + any unused blank ballots
signed by the Election Judge but not issued to voters.
E. Number of Unused Ballots
Prepare unused ballots for transfer to the general custodian of
F. Total number of ballots accounted for
(Add Lines B + C + D + E)
If this number is higher than Line A, the ballots are to be
transferred to the Central Counting Station to be counted.
G. Total number of ballots unaccounted for
(Line A minus Line F, include Supplemental Ballots
issued, if applicable.)
Regular ballots issued but not deposited into the ballot box
H. Total number of names on the Poll List or Combination
Forms or ePollbook.
Record the total number of voters who received ballots
including Provisional Voters
I. Number of Ballots in the transfer case
(Line H minus Line G)
If there is a difference of 4 or more between this line and
Station to be counted.
line B
, the ballots are to be transferred to Central Counting
Record the serial num
ber of the seal used on the transfer case :______________________
We, the undersigned election officials, do hereby certify that all voted ballots were placed in the transfer case(s)
to be transferred to the central counting station.
WITNESS MY HAND this _____________________ day of ________________________ 20_______
Presiding Judge: ________________________________ Clerk: ______________________________
Alternate Judge: ________________________________ Clerk: ______________________________
Poll Watcher (if present): __________________________ Clerk: ______________________________
Poll Watcher (if present): __________________________ Clerk: ______________________________
White copy (Envelope #1), Yellow copy (Unused ballots), Pink copy (Election Judge)