FORM OF OATH, SPECIFIED BY PART 8200.5100

Use this form only if you are registering to vote with a voucher as your proof of residence. I, _ (Name of Voucher) swear or affirm that (Check one): ( ) I am pre-registered to vote in this precinct Voter ID # _ (to be completed by the election judge) ( ) I registered in this precinct today and did not have another person vouch for me ( ) I am an employee of a residential facility _ (Name of residential facility) Residential Address of Voucher or Address of Residential Facility _ Street Address City Telephone number _ Email address (optional) _ I personally know that _ (Name of person registering) is a resident of this precinct. _ Signature of Voucher Election Judge Official Use Only: Subscribed and sworn to before me __/__/____ _ Date Signature of Election Judge The above oath shall be attached to the voter registration card and retained for at least 22 months.