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Poll Location: Vel Contact Person: IDELIVERY ~OG PAGE
Deliverto: Angelo Bible Contact #:
Equipment: SeriallD # Seal # Factory Seal" Technician Seal # Returned Delivery: Date & Time or Name
ACCESS TOUCH A1801967112 Departure Time: AM PM
ACCESS TOUCH A1801967812 Arrival Time: AM PM
Completion Time: AM PM
TOUCH T1901972501 Received by:
TOUCH T1901973701 Name:
TOUCH T1901980501 Name:
TOUCH T1901983901 Pickup:
TOUCH T1901984201 Departure Time: AM PM
TOUCH T1901991201 Arrival Time: AM PM
TOUCH T1901995201 Completion Time: AM PM
TOUCH T1901998101 Picked Up By:
TOUCH T1901970801 Name:
Name:
Supplies: How
Delivery Bag: Vinyl Envelope many
Tech Green Seal Green Paper Seal #: I, the Precinct Judge for the Booth Stands Election, do hereby certify that the seal number(S)
Verity Bag listed above are a true and correct list of the seals
Kiosk Bag Judge's Green Seal Red Paper Seal # used on Election Day.
Trifold (5)
Delivery Tub Record all red return seals for all equipment.
Orange Cone(s) RETURN Red Seal Boxed supplies are placed back in delivery bag, and Judge's Signature
supplies to be picked up by election staff are placed Table(s) together with equipment. Signs Return this form on clipboard to the Judge's Bag.
Alternate Judge's Signature
US Flag/PVC Pipe PRIMARY ELECTION 03/03/2020 Yellow Banner/Poles
Tech Green: Remvoed when delivered at poll, VC Yellow and Pink (leave on clipboard): Return in Yellow Judges bag at end of ED.
SPECIAL ELECTION Electionm Date 11/05/2019
You will need to use this/orm at the poll to verify the seriall.D. and seal numbers included on this/arm.
Vote Center: # 1 ANGELO BIBLE Controller 1 Serial #: C1801770908 vOrlve # Receive Seal #: Controller 2 Serial #: vOrive # Receive Seal #: I-----....,f------l
Check-In Kiosk Unit II: 1 Receive Seal II: r-------+-----~
Forms Kiosk Unit #: 21 Receive Seal II: ______L-____~ ~
Judge's Signature Judge's Phone II
Judges:
Please be sure to check that Ballot Box #3 and Provisional Ballot Box were delivered to poll and verify Seals and Locks.
Ballot Box #3: Delivered Not Sealed. Return with lock which is In the box.
lock It: VC 1 Red Wire Seal 8 Green Wire stat Door Seal It: •Provisional Ballot Box:
Judge must return and record items listed below: Controiler 1 Serial #: C1801770908 vOrlve # Return Seal II: Controller 2 Serial II: vOrive # Return Seal #:
Check-In Kiosk Unit II: 1 Return Seal II: Forms Kiosk Unit II: 21 Return Seal II:
Return Seal II: Rflurn Lock:Ballot Box 113:
lotk II: VC 1 Red WIre Setllt: Red WIre Slot Door Seal ~Provisional Ballot Box:
Power Cords: 0 Yes 0 No Judge's (Yellow) Bag: DYes o No
Facility Keys Returned: 0 Yes 0 No WiFI Returned: DYes o No
• .sweat/affirm that the above..aisted serial/seal numbers match the serial/seal numbers belng returned to the E1ectlon Office. If not, I have provided an explanation below,
Explanation: ______________________...-__________
Judge's SIgnature Printed noml!'
J, the undersigned outhorind elm oj the centrol counting starfan_ do hereby acltnowledQe receipt o} ~ above-listed ir.ms for VC 1, The items were deilwIred by (please
print}: __________ and __________ , two outhorized electIon t1/!1ce" oj rhot precinct and the seal numbel'$ match at tIu!
tlmf! ofdeltllftry,
Signature ~ Centl'(li Counting Arrival Time Departure Time
NOTE: Contact information for Election Office: 659-6541 or Vena: 234-7466
Tech Yellow: Removed at Dock pickup, VC Yellow and Pink (Leave on clipboard): Return in Judge's (yellow) bag at end of ED,
' 1'111 o~ CDunI)' Admlfl1prW\.lun t.'nmperulillun FornI "Mlrm"C4 b), rk St.'I;~~f} of Sailhi' JIoII} 7. 2008
H~f lorl'l Gft't'n C'0ti11l}' A«mrnllnl!! Pl.Jrp(lliC ~ OnlYI
STATEMENT OF COMPENSAnON
and OATHS
Name of Election Official (Please Print Legibly)
Complele Address (j , dude CilY Zio)
Social Security N umber
- -Home Phone ( )
Cell Phone ( ) email:
,
Position \Vorked '
Signature
r slate that the above is n true ond correct statement of the name, address and hours served
of the above lIumcd elect ion oflicia l conducting
the above rl(uncd election Hnd of the o ther expenses incurred in th is election.
Presiding Head Clerk/.Judge
Leave pages in folder
". swear (or affirm) that' will not in any manner request or seck to persuade or induce any voter to vote for or against any candidate or measure to be voted on, and that 1 will faithfnlly perform my du~' as an officer of tbe election and guard the purity of the election. I swear (or affirm) thnt 1 will not suggest, by word, sign or gesture, how the voter should vote; I will confine my assistance to answering the voter's questions, to stating the propositions on the ballot, and to naming candidates and, if listed, their political parties, and I will
prepare the voter's ballot as the voter directs, and I am not the voter's employer, an agent of the voter's employer, or an officer or agellt of a labor union to which the voter belongs."
Pel. No Authori ty Cundu ctlng [f tXliOIl Date Type of Election
Hours Worked Poll TOlal Rale Payroll ,,,,...I -;;;;~I from To Hours x ofP, Amount h!oC tl nl)JWorker
Please check in and
out when a lunch is
taken. See example ~lnot sure
/rOU'IO record.
To be compleled by
Tube f.:O lJ1pleled hy Elect
rite Judge >
ion Office>
D('livcry Fee
Training
Total
AW1·l6
Prrw d fl y ~etiifY Qf !ltoit.
~ctlol'r nOll, lexas f lection Code: 1<),11.<
Type or Ehxtion EV Blilnch/Vote Center
Date 01 Ek!ttion Authority Cancuctinr: Ele-ct \on
List of Provisional Voters
To be Completed by the Election Judge ,
To be Completed by the Ballot Board Judge
Name of Provisional Voter Acce pted for Counting Rejected for Counting
1
2
3
4
5
6
7
8
9
10
II
12
13
14
15
16
17
18
19
20
21
22
23
24
25 Number of PrOVIsIona l Ballots In Ballot 80)( las shown on Irst)
I certify that the numbers represented above are true and correct as evidenced by my signature.
Signature of I>'ecinct Presiding Judge:
Signatu re of Custodia n receiving baJiots Irom PreSiding Judge:
'Si8na~1Jreof Voter Registrar: _ _ ____ ____ _____ ____ _ _ _ _ _ _ _________
SEPARA TE FORM: Place green copy in Provsionol Bol/ot Box, yellow copy in yellow bog, and pink copy in
pink envelope
,\W7-1 I'rt~~nh('d h\ SCl"rclarv of Slall: S..'C'lIom; (lI.C) !' and (vi (U4 " Tcxu~ Ekct lon Codt \) ' I ~
Vote Cente r · Pet No, (N/ ill! D(' Prim
AUthority Conducti ng Election (AuloridwJ A dnllnJJI'lmillJ la V ecci6n)
Dille or EIl'e lion (I'ec/'o de k:J"'~lll/I)
Type of EJectiun (1'1110 dt! Eleccldl1)
OATHS (JURA ,HENTOS)
ASSISTANCE (ArUDA)
(Sec 64.034)
OATI-I OF PERSON ASSISTING VOTER: I swear (or affirm) that I will not suggest by word, sign, or gesture how the voter shall vote; I will confine my assistance to answering Lhe voter's questions, to stating propositions on the ballot. and to naming candidates and, if li sted, their political partics; I will prepare the ,'oter's ballot as the voLer directs; and I am not the voter's cmployer, an agent of the voter's employer, or an officer or agent ofa labor union to which the voter bdongs , (JURA MENTO DE I ,A PERSONA Q UI:: A )'UDA:1L VOTANTf: }'"(Jjuro (0 (~fiJ'm oj (/IU~ no slIgel'ife pOI" palabra, sena 0 accirin (:cimo dl!herl l votar t:I vOIunle: !ifni/an} mi £lyuda a cOl1lesfar las I)I'CKIIII/(JS del vulanle, (f de claro/' las prop osicialJes en I" bu/efa , Y () I/ombrar los candida/Os y, si Iistado:>. , 1m' portidos p ulilicos a 1/11i: p erleneccJI; yo prepul"arrJ la bo/cia " IJII l{) rlirUa el volant e. l ' no SO )' el e/llplcador (kl Volante, agenti! del emp/4.!lI£lor, () lfIl (!/icia/ 0 agcl1le de 1111 ,rinclicfflo d017de e/1'ofaJ1le p erlt!nef-"e,
INn:HPRETEH (fNTE111'IIETE) (Sec 61035)
INT ERPRETER'S OATIl: J swear (or affirm) that , to the best al'my ability, I will correctly interpret and translate each question, answer, or statement addressed either to the voter by an election officer or to an election onlcer by the voter. (JUR/IMI:.",/I,./T() DEL IlVTERP/?£T£: Yu/uro (u ({/irmo) que, a 1111 Ifl(;jor po(('nc:ia, inlerprel(Jl"ey Iradlll:ird de una munerO carrec/o cada pl'tgUl1lu respllt!.\"Iu 0 de clal'aciun que eua/qllier (~/icial elc.:t.:/oral dit/ja al VOlanl f! 0 que' ell 'o /anfe dirUa a clIal'luier q/icial electoral.)
The above oaths were sworn and subscribed to before me thi s _ __ day 01' -:-:,-,_,-,_.,.-_-,-, 20 ___ U os juramel1los ,\'ei111/(ldo.\' (ll'fibajlleron dec/uf ado.\' b'~iojllrameflft) y ,w scnfru unle (I'll enla}' ell(( ind/cada w -rihu.)
ELECTION OF FICER lone lAL £LECTORAI.!
Be sure to write the name of the assistant on the check-in combo form. Return in white bag.
AWS-17 Prescribed by Secretary ofState Section 84.032,84.038,86.0015 Texas Election Code REV 1012018
REQUEST TO CANCEL APPLICATION FOR BALLOT BY MAIL
To be completed by all voters intending to cancel their Application for Ballot by Mail:
I, ---------:-::--c-::--------~' a qualified voter for the _____________ (Print Name)
Election to be held on 1__ 1,___ request that my Application for Ballot by Mail be cancelled. (Month) (Day) (Year)
f~~T"""""'-~'I''"'~''-~''>tM~~'4W''''''''''''''''-~~-''''"",",,''''------''''''''''?'''-:>II' 1_~""__- __~____~::='':ZZl'_-''--'-;_"''''''' w
!
! Vl b i STATEMEJliT j <C ..... ! I am returning my mail ballot/presenting a Notice of Improper Delivery (circle one) to the early voting I ~ ~ I clerk/deputy early voting clerk/presiding election judge (circle the appropriate officer) and canceling my I j:!:! ..... I ballot by maiL
0<1:1 X >~ Signature of Voter
l l if~- qjl*""""'!;~""',,,,,,j!;N %H_";->"'1t[.¥-~,_-"t-:.:.,.,,,.jo<*,,,,'W'?_,, ""--~",",,,,:,,,>~>W'-.&.~~,~,,,,,*-=,,,,,,t~;.$;""'F-:_~_'r,",,-=---"'__~___..:ww..$__~.'1:'1'~,
i ! AFFlDAVIT A 1 ~ Affidavits A and B are only executed in person at the early voting clerk's office. These Affidavits Ilrt only used when the i voter is canceling hislher applicatiou with the EV e1erk after the close of early voting by personal appearance or on Election
, ~ Day, I c I, ------::c-:-.:-:----:---:---~' do hereby affirm that I have not received my mail ballot at the! (Print Name)I I
i !
time ofmaking my request to cancel my Application for Ballot by ~_ai_L_______________.1, f..... OR Signature of Voter<I:
2: ; AFFIDAVIT B !w I I, _____-:-::-:_-::--:_____' do hereby affirm that I have not requested a mail ballot::> ! i
<,( i (Print Name)
b J:
i X-------·----------------- lOR
z Signature of Voter \I)
! I Iw AFFIDAVITCo Affidavit C is only executed in person at the early voting tJerk's office. It must be executed before the <:artier envelope IsC
delivered to the early voting ballot board. 0:: LU ,t
I hereby request that my mail ballot be canceled. I, __-::::-:---:,.,-_,--__ affmn that I did not b 1 (Print Name) ::> I! mark my ballot that was sent to me by maiL
X------------------------ I Signature of Voter t
"",,.-,:; "c",,~"~,_ '0"_",,,,.,,_,,,,,,-",, """'."'"'._.....~~n',A';o>'____ =. <;C:''-'''l't'h ~ _""""~_""_h _~_ ,"'-.,.._-.="'.....-~-"'..~,""""~"".",.,...,__ ,=-~~.,~'''''''''-'''''*'__....~••,;,,.,.. '.,,,,=n,, ""',....,~,,,-~"'\_,,,>v~"'""'.,f ,
This section to be completed by early voting derk, deputy early voting clerk, or election judge.
VUID _____Name of Voter Voter's Precinct Number _____ (Print Name)
Sworn to and subscribed before me, this ___ day of__~ ..~_.. ________~____,20 __~~-(Month) (Year)
x__~----~~~~ __~-~ Signature ofOfficer Administering Oath
Denied ____ Reasoo____.______________ Date --1--1-- ]
/1 ',1/1.8 P1fl;tc,,/'o.d by Secretary c.f Slare Se:::nan ft1.0070 Tex as So.::;.elary 01 Slil l!' 3107
Election: Constitutional
Date: 1110312015
Vote Center:
Notice of Total Number of Voters Who Have Voted (Aviso del Numero de Volanles Que Han Volado)
Number of Voters (Numero de Votantes)
9:30 AM
11:30 AM
1:30 PM
3:30 PM
5:30 PM
Signature of Presiding Judge (Firma del Juez Presidenle)
NOTE TO PRESIDING JUDGE: The total number of voters as shown on the poll list shall be posted at the times listed. The notice shall remain posted until the polls close . Return this form in White Bag to the general custodian of the election records.
NOTA AL JUEZ PRESIDENTE: Ef nlimero de votantes estab/ecido en /a lista de votantes se mostrara a las horas seflaladas arriba. EI aviso quedara puesto hasta que cierren los s;t;os de votac;on. Devuelva esta forma en /a bo/sa amarilla (el sobre nlimero 2) a la persona a cargo de los archivos e/ectora/es.
EV BranchlVote Center #: ___ _
Date:
All Poll Workers:
You must read, sign and date that you have read the Tom Green County Computer Security Policy on the left: of this signature form. By signing you are affirming you will comply with this policy.
Date Name SiQnature
,
Leave this signed form in this folder.
Cancelled Check In Voter List VOTE CENTER LOCATION ____________________
ELECTION: ___________________________ DATE: _________________
CERT # LAST NAME FIRST NAME REASON FOR CANCELLATION [Place label in
sleeve or if label is adhered to combo sheet, with a red pen write "cancelled" across label]
Judge's Signature
Write "Cancelled" on the 3 VoteSafe labels in red and initial. If not taped to forms, insert them all in the un-used labels sleeve . Once the voter has been Cancelled their screen will
look like an original voter check in screen. Cancelled check in voters are not counted in totals.
RETURN THIS FORM WITH YELLOW CHECK - IN SIGNATURE FORMS
USED OR NOT
( ( ( Party Affiliation Change
requested changed to ...~----------~------~~~----~
Name IAddress Republican I Democrat Republican j Democrat comment
1-----------11-----------;
--------...1.-- ..---'
Sleeve: Beginning of Day Access Code Report
Election Day Election: Vote Center:
Date of Elect ion : Au thority Conducting Election.
Beginning of Day Public Count from Judge's Booth Controller (.TBC) 1
Beginning of Day Public Count from Judge's Booth Controller (JBC) 2
From Judges Booth Controller (JBC) Access Code Report
__ Check to indicate JBC tapes have been placed in sleeve.
Signature of Judge
Leave sleeve in folder, return entire folder in YELLOW BAG
Sleeve: Beginning of Day Access Code Report
Election Day Election: Vote Center:
Date of Eleclion : Authority Conduct ing El ection:
Beginning of Day Public Count from Judge's Booth Controller (JBC) 1
Beginning of Day Public Count from Judge's Booth Controller (JBC) 2
From Judges Booth Controller (JBC) Access Code Report
_ _ Check to indicate JBC tapes have been placed in sleeve.
Signature of Judge
Leave sleeve in folder, return entire folder in YELLOW BAG
Cancelled Booth Log .
Election: ________________ Polling Place: ______________ Date of Election:___________ Authority Conducting Election: _____________
Directions for Cancelled Booths: If you must cancel a booth use this log to record the date and time cancelled, who cancelled the booth, and the reason it was cancelled. Expired codes are placed in separate sleeve.
[Thrown Out = Voter did not cast ballot] [Spoiled = voter chose wrong language or we gave them wrong ballot style]
Date Time Cancelled by Voter didn’t cast ballot (√)
Thrown Out
Voter chose wrong language(√) Spoiled
Voter given wrong ballot style (√) Spoiled
Other
If USED, place in FORMS SIGNATURE ROSTER ENVELOPE. If NOT USED, leave form in Ballot Station Binder.
Expired Code Log .
Election: ________________ Polling Place: ______________
Date of Election:___________ Authority Conducting Election: _____________
Expired Codes are codes that were issued but never entered in the eSlate.
If USED, place in FORMS SIGNATURE ROSTER ENVELOPE. If NOT USED, leave form in Ballot Station Binder. G:prepping elections/VC Delivery Bag Bags and Paperwork/Ballot Station Bag/Ballot Station Binder/vona expired code log
Date Time Processed by Reason expired
Click on Counts and Logs to get the numbers for the reconciliation. Be sure to click on the Provisional tab to get that count also.
If you click on Logs, you will see the names of the voters checked in on that Kiosk. This can be used if you need help balancing.