AFFIDAVIT TO PICK-UP VOTE-BY-MAIL BALLOT FOR A VOTER
I _hereby swear or affirm that
(Print the designee’s name) (Print the voter’s name)
has authorized me to pick-up a vote-by-mail ballot on his or her behalf for the .
(Specify for which election)
Check applicable box:
I am not a member of the voter’s immediate family, or
I am a member of the voter’s immediate family and my relation to the voter is .
(Relationship)
I understand that any person who perpetrates any fraud in connection with any vote to be cast violates s.
104.041, F.S., and can be convicted of a felony of the third degree and fined up to $5,000 and/or imprisoned for up
to five years. Under penalties of perjury, I declare that I have read the foregoing affidavit and that the facts
stated in it are true.
Designee’s Signature Date
For office use only:
Designee provided the voter’s written authorization as a separate document ____ or voter completed the
Voter’s Written !uthorization for Designee (see below) ____
Designee produced the following picture identification:
(Type of identification)
An authorized designee may pick up a ballot any time within 9 days of election day including election day.
A designee is limited to picking up a ballot for himself or herself, for members of his or her immediate family, and for up to
2
other voters per election.
A vote-by-mail ballot request for the voter must already be on record by law (section 101.62(1)(b), F.S.) Otherwise, the
written authorization must include the information required for a vote-by-mail ballot request, or other confirmation
obtained from the voter.
Voter’s Written Authorization for
Designee
(To be completed only if separate voter’s written authorization not submitted)
I / hereby designate
(Voter’s name-printed) (Voter’s signature)
to pick up my vote-by-mail ballot for the .
(Print designee’s name) (Specify for which election)
Attention: Provide the following additional information if you (the voter) do not already have a vote-by-mail
ballot request on record:
Voter’s date of birth (MM/DD/YY) Voter’s address
DS‐DE 37 (rev. 07-2019)
s.101.62(4)(c)4., Fla. Stat.
