(SECTION 101.62(4)(C)5., FLA. STAT.)
(NOTE: ALL INFORMATION ON THIS FORM BECOMES A PUBLIC RECORD WHEN SUBMITTED TO THE SUPERVISOR OF ELECTIONS’ OFFICE.)
I hereby swear or affirm that:
1. (Check applicable box)
I, ___________________________, am the voter requesting the vote-by-mail ballot;
(Print the voter’s name)
or
I, ___________________________, have been designated by ___________________________.
(Print the designee’s name) (Print the voter’s name)
2. (Check box and complete entry)
The voter cannot go to the assigned polling place on this Election Day: _____________________
(Specify the election date)
because of the following emergency (THIS INFORMATION BECOMES PUBLIC RECORD):
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
I understand that any person who willfully affirms falsely to any affirmation in connection with
elections and any person who perpetrates any fraud in connection with any vote to be cast in an
election violates sections 104.011 and 104.041, Florida Statutes, 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 each of the named
statutes.
Under penalties of perjury, I declare that I have read the foregoing affidavit and that the facts stated
in it are true.
___________________________ ___________________
Signature Date
FOR OFFICIAL USE ONLY, TO BE COMPLETED BEFORE DELIVERY OF VOTE-BY-MAIL BALLOT: No vote-by-mail ballot can be
delivered to a voter’s designee unless the designee provides picture identification; the voter provides a separate written
authorization for the designee to pick up the ballot; and the designee provides a separate affidavit under s. 101.62(4)(c)4.,
Fla.Stat., stating that the designee is authorized by the voter to pick up the ballot.
Check the applicable boxes (all must be checked before delivery of the ballot to a designee) and sign:
The designee provided picture identification.
The designee provided the voter’s written authorization or the voter’s written authorization was already on file.
The designee provided the separate affidavit required by s. 101.62(4)(c)4.,Fla.Stat.
___________________________ ___________________________
Election official’s name Election official’s signature
