DS-DE #117 (rev. 07/2011)/R1S-2.041, F.A. C.
FLORIDA DEPARTMENT OF STATE/DIVISION OF ELECTIONS
Certification of Address List Maintenance Activities
This form is to be used to certify that a Supervisor of Elections has conducted activities
required under Section 98.065, Fla. Stat., to maintain current and accurate residential
addresses for registered voters.
I, _______________________________, Supervisor of Elections or designee, for ______________
County, certify that the following address list maintenance program activities(check all that apply) were
conducted January 1, ________ to June 30, ______, or July 1, _______ to December 31, _______:
Change-of-address information from U.S. Postal Service/NCOA
Mass (nonforwardable) mailing to all registered voters in county
Targeted address confirmation request (nonforwardable) mailing to registered voters who have
not voted or requested an update to their records within the last 2 years
ACTIVITY: ADDRESS CONFIRMATION REQUESTS (ACR) (provide total number)
Address confirmation requests sent
ACTIVITY: ADDRESS CHANGE NOTICES (ACN) (provide total number)
Address change notices sent
ACTIVITY: ADDRESS CONFIRMATION FINAL NOTICES (ACFN) (provide total number in each category)
Address confirmation final notices sent
Registered voters who responded to address confirmation final notices
ACTIVITY: PLACEMENT ON INACTIVE STATUS (s. 98.065(4)(c), F.S.) (provide total number in each category)
Registered voter record placed on inactive status
(this includes only those voters for whom an address
confirmation final notice was undeliverable or who did not respond to the notice within 30 days)
ACTIVITY: REMOVAL OF INACTIVE REGISTERED VOTERS (s. 98.065(4)(c), F.S.)
Number of inactive registered voters removed from the statewide voter registration system
(these are registered voters who were placed on the inactive list and who for two general election cycles
thereafter did not vote or try, did not request an absentee ballot, nor updated their registration record)
______________________________________________________ _______________
Supervisor of Elections or designee (signature) Date
Please submit form no later than July 31 (for January through June activities) or no later than January 31 (for July through
December activities) to: Chief, Bureau of Voter Registration Services, Florida Department of State/Division of Elections,
R.A. Gray Building, 500 S. Bronough Street, Tallahassee, Florida 32399; 850/245-6290 (phone), 850/245-6291 (fax)
