Sample Election Forms

September 2016

Before 7 a.m. on Election Day, all election workers, including the Presiding Election Judge, must repeat aloud the oath at the top

left side of the form. This constitutes being sworn in. If other clerks arrive later (split shift) they must also do the same.

Each election worker receives their own Statement of Compensation and Oaths form. The Presiding Election Judge must sign each

Statement of Compensation and Oaths form.

In the event an election worker does not meet the eligibility requirements, the Presiding Election Judge should call us immediately

if needing our assistance in finding eligible workers to assist you.

After checking eligibility requirements, each worker must complete his/her own Statement of Compensation and Oaths form. Be

sure all information requested is provided. We cannot process payroll without a Social Security number. Please be sure to provide

your email address and telephone numbers in the event questions arise and we need to contact you.

Election Day Hours - TIME IN is when election worker begins work at the polling place on Election Day. TIME OUT is when

electionworkerendsworkatthepollingplaceonElectionDay. PleasebesuretocircleAMorPM. Do not include travel time to

the Rally Station. Delivery is paid at a flat rate. Please do not record time in military format. Meals are not reimbursable. Do

not deduct time off for meals, unless time off exceeds 1 hour.

Election Law Training (2700 Premier Street) and Online Training Programs – When applicable, training compensation is

$10 per hour. Compensation for online training will not exceed the amount paid to those who attend in-person training. Please

circle “yes” or “no” in this section.

Delivery of election results and supplies - The delivery fee is $25 ($15 for primary elections). If two election workers indicate

“yes”, the delivery fee will be divided equally. Please circle “yes” or “no” in this section.

Personal Cell Phone Use - If the election judge uses their personal cell phone, reimbursement is a flat rate of $10 ($5 for primary

elections). Compensation will be given for only one cell phone per polling place. If usage exceeds $10, actual charges may be

reimbursed upon receipt of a copy of the phone charges. If you are requesting payment for cell phone, we must have your cell

number and that cell phone must be “on” from 6:00 a.m. until all of your supplies have been delivered to the designated Rally

Station.

Are you bilingual? - Please circle “yes” or “no” in this section.

Position you served in today - Please place a √ next to the appropriate position in which you served today.

Please do not write in the section designated for office use.

Instructions for Statement of Compensation and Oaths Form

NOTE: Before the polls open, all election officers

(Presiding Judge, Alternate Judge and Clerks)

should repeat the oath aloud with their right hand

raised. Confirm everyone is eligible to serve.

Complete this

section in full.

Payroll cannot

be processed

without a

Social Security

Number.

Be sure to

provide email

address and

telephone

numbers.

Complete this section in full.

Do not write in the section designated for office

use only.

Each worker must

complete page 8 of the

Cornerstone Notice of

Network Requirements

packet only once, not

each election.

Return completed form

with Statement of

Compensation and Oaths

Form.

Pages 1 through 7 are

retained for your records.

Top Portion

Bottom Portion

Top Portion

Bottom Portion

Number of ballots issued per precinct

Special Circumstances:

Statement of Residence Required

voter completes Statement of

Residence BEFORE voting

Early Voted

voted early in person

Voted by Mail

voted by mail

Mail Ballot Requested

mail ballot requested, call Early

Voting to confirm status

List of Registered Voters

from Poll Book

Match the “Ballot Code” from the Combination Form to

the ballot code “Precinct ID” on the ballot

1002-002

It is imperative the correct ballot code is selected!

eScan Ballot

Match the “Ballot Code” from the Combination Form to the ballot

code “Precinct ID” on the Add Voter Screen of the JBC

1001

It is imperative the correct ballot code is selected!

eSlate Ballot

VOTER REGISTRATION APPLICATION

(white card)

Give a Voter Registration Application to any

unregistered person. The application may be returned

by mail or you can receive the application and return it

in Envelope 4.

STATEMENT OF RESIDENCE

(yellow card)

Give a Statement of Residence card to voters with the “Statement of

Residence” notation on the List of Registered Voters and voters who

have moved from the address on the List of Registered Voters. The

card MUST BE COMPLETED and returned to the election official before

voting. Return in Envelope # 4. NOTE: If the new address is outside

Tarrant County, the voter may only vote by provisional ballot. Have the

voter complete the card and a Voter Registration Application, which we

will forward to their new county of residence.

POLL LIST

INSTRUCTIONS:

Important: The Poll List is

completed by the Election Judge

or clerks. The voter does NOT

enter his or her own information.

It is fine to complete multiple

copies of the Poll List

simultaneously, if using more

than one check-in table. Be sure

to combine the lists and number

them at the end of the day.

Ifyouhavemultipleprecincts,

you are not required to complete

separate Poll Lists for each

precinct. One Poll List will suffice

for all precincts.

Use the number of names

entered on this form to complete

line 16 on the Register of Official

Ballots.

Oaths

Assistance / Interpreter

It is recommended that the Presiding

Election Judge administer these

oaths aloud.

Each person who assists a voter in

marking his/her ballot or who serves

as an interpreter for a voter must

take the appropriate oath prior to

rendering assistance or interpreting.

All persons except the election judge

and clerks must take the oath each

time they render assistance or act as

an interpreter.

Use slip to ensure correct ballots are issued to voters when there

are two or more ballot styles.

Remember, each precinct has at least one ballot style.

 Election clerk notes voter’s Precinct / Ballot Code on the slip

and gives slip to voter.

 Voter presents slip to election clerk manning ballot table.

 Slip is reviewed by clerk who directs voter to the correct stack

of ballots voter may choose from.

Processed Voter Slip

PRECINCT: 1002-002

BALLOT CODE:

Voter Registration Certificate

Includes the voter’s political subdivisions and districts

If a voter has

applied for and

received a

permanent

exemption to the

photo ID

requirement, their

Voter Registration

Certificate will

have an (E)

notation.

Voter’s Similar Name Correction Request Form

Provide form to voters who would like to update

their name on their voter registration record.

Provisional Envelope (front)

Voter completes the entire Affidavit of Provisional Voter (white section). Election official completes the left

green section. D

O NOT separate the two sections.

Write the Ballot Code from the Voter

Provisional Stub that’s printed on the JBC tape.

(see page 20 of this packet)

Provisional Envelope (back)

The election official must complete the left side indicating, 1) if the voter presented an acceptable form

of photo ID and 2) the “reason” the voter is casting a provisional ballot. The election official must

also date and sign the envelope. This is a critical step in processing a provisional voter.

List of Provisional

Voters - record of

the voters who vote

provisionally on

Election Day.

Processing Provisional Voters on the JBC

Ballot Code: Enter code (circled in red) on the front of the Provisional Envelope. (See page 17 of this packet)

Provisional Sign-in Sheet

Located in the back of the Poll Book

Provisional Sign-in

Sheet - voters who

vote provisionally on

Election Day must

sign this form.

Request to Cancel Application for Ballot by Mail

If the mailed ballot is not

presented by the voter,

please call Early Voting at

817-831-6161.

Post this notice on

an outside door of

the polling place;

one which a voter

will most likely use

when entering the

building.

Notice of Total Number of Voters Who Have Voted

Voters may spoil up to two

ballots and vote a third

one. Write the voter’s

name and the serial

number of the spoiled

ballot on the Register of

Spoiled Ballots.

Each spoiled ballot is

sealed in a small white

Spoiled Ballot envelope to

ensure privacy.

The small white Spoiled

Ballot envelope is placed in

the large Spoiled Ballots

envelope.

The large Spoiled Ballots

Envelope is returned in the

black eScan tub at the

close of polls.

The ballot’s serial number

is located on the front of

the ballot, on the lower

left corner.

If a ballot is spoiled, this

number will be written on

the Register of Spoiled

Ballots.

Ballot Serial Number