FLORIDA DEPARTMENT OF STATE/DIVISION OF ELECTION
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DS DE# 118 (rev.07/2011)/R1S-2.041, F.A.C.
Certification of Eligibility Records Maintenance
This form is to be used to certify that the Supervisor of Elections conducted activities as
required under section 98.075, F.S. to identify and remove ineligible voters from the voter
registration rolls.
I, ____________________________________, Supervisor of Elections or designee, for
______________ County, certify the following for the period January 1, _____ to June 30,
_____, OR July 1, _____ to December 31, _____ :
A. ACTIVITY: NOTICE OF POTENTIAL INELIGIBILITY ( provide total number for each category)
Notices mailed (s. 98.075(7)(a)1., F.S.)
Notices published (A notice is published ONLY if the mailed notice came back undeliverable
which includes unclaimed, refused, or otherwise marked as undeliverable). For notices including
voters, provide the number as if it were a notice per voter) (s. 98.075(7)(a)2., F.S.)
B. ACTIVITY: RESPONSES TO NOTICES (MAILED OR PUBLISHED)
Voters who responded to mailed notices
Voters who responded to published notices
Number of hearings conducted (this should be the same as the number of voters who
responded to either a mailed or published notice and requested a hearing (such hearing can
only be requested by and held for persons who deny ineligibility)
CTIVITY
UMBER OF
OTERS
EMOVED
ASED ON
EASONS FOR REMOVAL
Convicted felon with no civil rights restored/no clemency
.
Mentally incapacitated without voting rights restored (Refers to voters whom the court has
declared to be mentally incapacitated AND taken away their voting rights/civil rights)
Deceased (Refers to deceased voters removed with or without notice based on death data match
identified by the state, receipt of in-state death certificates or information received from other
Not of legal age to register
Listed a residence that is not his or her legal residence (Refers to voters who listed someone
else’s legal residence, or who listed a residence that is not a valid legal residence)
Fictitious person (Includes registered voters with fake names and/or date of birth or who use
someone else’s residence, name or date of birth to register)
________________________________________ _______________
Supervisor of Elections or designee (signature) Date
Please submit by deadline [July 31 for Jan–Jun) or by January 31 for Jul-Dec) to: Chief, Bureau of Voter
Registration Services, Fla. Dept. of State, Division of Elections, R.A. Gray Building, 500 S. Bronough Street
Tallahassee, Florida 32399; 850/245-6290 (phone) 850/245-6291 (fax)
