________________________________________ __________________
________________________________________ ___________________
________________________________________ __________________________________
Election Coding Statement
NOTICE:
1. Anyone who knowingly makes a false statement in writing with the intent to mislead a public servant
in the performance of his or her official duty shall be guilty of a misdemeanor of the second degree,
punishable as provided in Section 775.082 or 775.083, F.S. (Section 837.06, F.S.)
2. Anyone who knowingly and willfully makes any false, fictitious, or fraudulent statement or
representation or makes or uses any false document, knowing the same to contain any false, fictitious, or
fraudulent statement or entry within the jurisdiction of the Department of State is guilty of a felony of the
third degree. (Section 817.155, F.S.)
I certify that the election coding for the __________________________________
(Insert name of election)
to be conducted in _______________________ County on _________________
(Insert name of county) (Insert Election Date)
was assembled according to specified procedures for the
__________________________________________________________________.
(Insert name of voting system and its Florida certification number)
To the best of my knowledge and belief, the foregoing statement is true and
correct.
(Signature of person who coded the election) (Date)
(Printed name of person who coded the election) (Telephone number)
(Name of the entity employing above person) (Work email address of above person)
This document is a public record upon filing.
DS-DE 132 (eff. 4/2016) Rule 1S-2.015, F.A.C.
