__________________________________________________________________________________________________
P
ROVISIONAL
B
ALLOT
C
URE
A
FFIDAVIT
–I
NSTRUCTIONS AND
F
ORM
This affidavit is for a voter whose provisional ballot certificate does not include the voter’s signature or whose signature
does not match the voter’s signature on file.
A. Instructions. READ THESE INSTRUCTIONS CAREFULLY BEFORE COMPLETING THE AFFIDAVIT. FAILURE TO FOLLOW THESE INSTRUCTIONS MAY
CAUSE YOUR BALLOT NOT TO COUNT. In order to cure the missing signature or the signature discrepancy on your Provisional
allot Voter’s ertificate and !ffirmation, your affidavit should be completed and returned as soon as possible so
that so it can reach the supervisor of elections of the county in which your precinct is located no later than 5 p.m.
on the s e c o n d day after the election. You must:
Complete and sign the affidavit below - sign on the line above “(Voter’s Signature)”
Make a copy of one of the following forms of identification (ID):
Tier 1 identification - Current and valid ID that includes your name and photograph: Florida driver license; Florida
identification card issued by the Department of Highway Safety and Motor Vehicles; United States passport; debit or credit
card; military, student, retirement center, neighborhood association, or public assistance ID; veteran health ID card
issued by U.S. Department of Veterans Affairs; Florida license to carry a concealed weapon or firearm; or employee ID card
issued by any branch, department, agency, or entity of the Federal Government, the state, a county, or a municipality.
OR if you do not have one of the above forms of ID, use one of these instead:
Tier 2 identification - ID that shows your name and current residence address: current utility bill; bank statement;
government check; paycheck; or government document (excluding voter information card).
Return the completed affidavit and the copy of your ID to your county supervisor of elections:
Deliver in person or by someone else,
Fax or email (attach the completed affidavit and copy of the ID), or
Mail, if time permits (insert the completed affidavit and copy of the ID into a mailing envelope and address to the
supervisor; be sure there is sufficient postage and the supervisor’s address is correct)
Address, fax numbers, and email addresses for each Supervisor of Elections can be found here:
http://dos.elections.myflorida.com/supervisors/
Remember, your information MUST reach your county supervisor of elections no later than 5 p.m. on the 2nd day following
the election or your ballot will not count. Submitting a provisional ballot affidavit does not establish your eligibility to vote
in this election or guarantee that your ballot will be counted. The county canvassing board determines your eligibility to
vote through information provided on the Provisional allot Voter’s ertificate and !ffirmation, written evidence provided
by you, including information in your cure affidavit along with any supporting identification, and any other evidence
presented by the supervisor of elections or a challenger. You may still be required to present additional written evidence
to support your eligibility to vote.
B. Form
Provisional Ballot Cure Affidavit
I, __ , am a qualified voter in this election and a registered
voter of _____________________ County, Florida. I do solemnly swear or affirm that I
voted a provisional ballot and that I have not and will note vote more than one ballot in this election. I understand that if I
commit or attempt any fraud in connection with voting, vote a fraudulent ballot, or vote more than once in an election, I
may be convicted of a felony of the third degree and fined up to $5,000 and imprisoned for up to 5 years. I understand
that my failure to sign this affidavit will invalidate my ballot.
Voter’s Signature Voter’s Address
Form DS-DE 210 (eff. 07-2019) Florida Department of State/Division of Elections Section 101.048, Florida Statutes
