SIGNATURE ROSTER COVER

Return to: Secretary of State County Clerk District Court Magistrate Court

County:

Polling Location:

Election Name	Election Date	Counting Group
		Early Election Day

PART 1 – BALLOT ACCOUNTING

TABULATOR TOTALS

Tabulator Serial #				TOTAL
Tabulator Serial #
Total ballots cast from tabulator tape(s)	+	+	+
				(A)

HAND TALLY BALLOT TOTALS

Total HAND TALLY ballots from each hand tally bin		+		+		+
Enter ZERO (0) if none								(B)

PROVISIONAL BALLOTS VOTED

Count the number of PROVISIONAL BALLOTS that were issued.

Enter ZERO (0) if there are no provisional ballots

(C)

TOTAL BALLOTS VOTED	PART 1 TOTAL
TOTAL all ballots voted: Tabulator Totals (A) + Hand Tally Ballot Totals (B) + Provisional Ballot Totals (C) and enter the quantity here:		Box 2 =

PART 2 – VOTER (SIGNATURE) ACCOUNTING

TOTAL NUMBER OF VOTERS

PART 2 TOTAL

Count the number of SIGNATURES in the roster and enter the quantity here:
(Hint: total the number of signatures on each page then add all)

Does the TOTAL BALLOTS VOTED = TOTAL NUMBER OF VOTERS
(Does Part 1 Total = Part 2 Total?)

YES NO

If "NO," explain discrepancies here:

PART 3 – DESTROY UNUSED PRE-PRINTED BALLOTS

We certify that all unused ballots (box 3) were publicly destroyed at the polling place as follows:	Total ballots received	Box 2: Total ballots voted	Total ballots spoiled and found in spoiled ballot envelope	BOX 3: Total ballots unused and destroyed
		-	-	=

PART 4 – CERTIFICATION

We, the undersigned election officials, do hereby certify that this signature roster contains all of the signatures of the voters who voted in this location during this election, with any exceptions noted, and that no person was permitted to vote whose signature or mark does not appear on the roster.

Presiding Judge

Election Judge

Election Clerk