CHALLENGES TO VOTER REGISTRATION, FORM TO BE USED UNDER MINNESOTA STATUTES, SECTION 204C.12 , SUBDIVISION 2

I, _ , do hereby state under oath, Name of person making challenge I am: ( ) an election judge. ( ) a challenger authorized by Minnesota Statutes, section 204C.07 . ( ) a Minnesota voter. I reside at _ , _ , Street Address City or Township Telephone number: _ Email address (optional): _ I challenge the registration of _ Name of challenged voter whose registration lists his or her residence as _ _ Street Address City or Township This challenge is based on my personal knowledge. The grounds for my challenge are: _ _ _ (attach additional sheets of signed statement if necessary). I swear or affirm that the information stated here is truthful. __/__/____ _ Date Signature of Challenger Signed and sworn to or affirmed before me __/__/____ _ Date Signature of Election Judge For Election Judge Use Only: Challenge was administered by Election Judge: _ Time: _ ( ) Voter refused to take challenge oath. ( ) Challenge was dismissed: Voter passed challenge and voted. ( ) Challenge was sustained: Voter failed challenge and did not vote. Additional Comments: