PROVISIONAL VOTERS INFORMATION FACT SHEET FORMULARIO DE DATOS PARA ELECTORES PROVISIONALES Dear Voter: Estimado votante: I am sorry but the Election Board Worker did not find your name on the Official Precinct Register. We apologize for the inconvenience and will make every effort to rectify the situation. In continuing, you must swear to the following facts, provided they are true. If they are not true, then I am sorry, but you may not meet the qualifications to vote in this election. Lo siento, pero el trabajador de la Junta Electoral no encontró su nombre en el Registro Oficial del Distrito Electoral. Pedimos disculpas por el inconveniente y se hará todo lo posible para rectificar la situación. Al continuar, debe jurar a los siguientes hechos, siempre y cuando sean la verdad. Si no son la verdad, entonces lo siento, pero usted no puede cumplir con los requisitos para votar en esta elección. Completing this form affirms that the following information is true. I swear or affirm that the following facts are true: • I am currently a registered voter in this county. • I have not resided or registered in any other county or state since registering to vote. • I have not voted and will not vote in this election except in this precinct if authorized to vote. Al llenar este formulario declaro que la siguiente información es cierta. Juro o declaro que los siguientes hechos son ciertos: • Estoy actualmente registrado para votar en este condado. • No he residido ni me he registrado en ningún otro condado o estado desde que me registré para votar. • No he votado y no votaré en estas elecciones al menos que se me autorice en este distrito electoral para votar. If the answer is yes to the above three statements, please continue by completing the following information. (Please print legibly) Si la respuesta es sí a las tres declaraciones anteriores, por favor continúe completando la siguiente información. (Por favor letra de molde legible) __________________________ ________ First Name MI Primer Nombre _______________________________ Last Name Inicial de Segundo Nombre Apellido ____________________________________________________________ Present address: House number and street Dirección actual: numero de casa y nombre de calle PO Box (if applicable) City Correo Postal (si es aplicable) Ciudad ______________________________ Date of Birth (Month, Day and Year) ____________________________________ Previous name or maiden name if applicable Fecha de nacimiento (Mes, Día y Año) Nombre anterior o apellido de soltera si es aplicable Please hand back to the election worker after completing the above information. Por favor devolver al trabajador electoral después de finalizar la información anterior. *******************La siguiente información es solamente para el trabajador electoral******************* Election Worker’s Name: ____________________________________ Call the Clerk’s Office at (402) 987-2127. Please have the Voter complete the preceding information and give the clerk’s employee the information when calling the office. You should document the following information when talking to the clerk’s office. Name of County Clerk’s Employee assisting you: _____ Ted _____ Cherie _____ Mary _____ Election Piepho Conley Wiltgen Board Did the Election Official authorize this person to vote? _____ YES _____ NO Identify the precinct where the voter should vote _______________________________ Look on the backside for polling place and address and circle it. Identify the Ballot that the voter should receive. _______________________________ The Ballot style is important because it identifies what offices the voter is entitled to vote such as school district, city council, NRD etc. If the County Clerk’s Office approves the voter to vote then an Election Board Worker should help them complete the Provisional Ballot Envelope Certificate. This form should be inserted in the pocket attached to the Provisional Ballot Envelope along with a Provisional Voter Instructions and a completed Voter Registration Card and allowed to vote. If the voter must go to a different precinct, please give the voter this fact sheet and advise them where to go by circling the precinct information on the back. By presenting this form to the new precinct with the Election Board Worker’s signature and the clerk’s office authorizing the person to vote, the Election Board at the new precinct is authorized to process the voter as a PROVISIONAL VOTER. CITY OF SOUTH SIOUX CITY 01 WARD 1 River Hills Assembly of God Church 1101 5th Avenue South Sioux City, Nebraska CITY OF DAKOTA CITY 08 DAKOTA CITY Dakota City Council Chambers 1511 Broadway Dakota City, Nebraska RURAL PRECINTS 02 WARD 2 07 COVINGTON ISLAND South Sioux City Fire Hall 201 W 16th Street South Sioux City, Nebraska Knights of Columbus Hall 1805 W 29th Street South Sioux City, Nebraska 03 09 WARD 3 DAKOTA RURAL South Sioux City Legion Hall 109 East 19th Street South Sioux City, Nebraska Salem Lutheran Church 1753 G Avenue Dakota City, Nebraska 04 10 WARD 4A EMERSON First Lutheran Church 3601 Dakota Avenue South Sioux City, Nebraska Emerson Legion Hall 109 N Main Street Emerson, Nebraska 05 11 HUBBARD WARD 4AA First Lutheran Church 3601 Dakota Avenue South Sioux City, Nebraska Hubbard Community Center 310 Nebraska Street Hubbard, Nebraska 06 12 WARD 4B S Sioux City Middle School 3625 G Street South Sioux City, Nebraska OMADI Homer Legion Hall 22 John Street Homer, Nebraska 13 ST. JOHNS Jackson Legion Hall 103 Elk Street Jackson, Nebraska