Ring - Vote-by-Mail Data Request - 9-2-22 t` uu..0.P 4
h;�tE‘ . 0 ,��/ VOTE BY MAIL DATA
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REQUEST FORM
. Duval County Supervisor of Elections
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Vote by mail information is confidential and exempt from public disclosure under section 101.62(3),F.S.,except to the following
persons or entities that may request and use it for political purposes only:
❑ Political Committee (Provide committee name)
❑ A Political Party or Official (Provide party/official name) S S
II Candidate who has filed qualification papers & is opposed in an upcoming election (Race: 1 � �,t_cv`\m‘SS1C5Wtv-)
211%)Election Cycle: Z
Data requested: YAII Parties nDemocrat ❑Republican uOther
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Name: \�P�� c rc) Title/Office �S`n Y�C5( �`\S
Street Address: QUO T€;),2'r) t o +" Phone: 6101 l-\L c. - (e 6 ZZ
City/State/Zip PA\ tic C 1 I !"L f 3 z Z 3 3 Email: \'‘r( v``a IA 6 wank`` coin
I affirm that I am a person authorized by Section 101.62(3), Florida Statutes,to acquire vote by mail information.
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SIGNA,� OF PERSON REQUESTING INFORMATION DA
The foregoing instrument was acknowledged before me
this
Z day of e Y`n �' , 2,(✓L2 by
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persot nown�by me or whlo�presented � COMMISSION#HH 22G; ..
as identification. E
EXPIRES:February 8,204
Notary Name: L•Cu*C-lam{ Y‘.
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Notary Signature: 2G Z
Commission Expiration Date: V . I )C
I:I also designate the following person acting on my behalf to receive and use my username and password to obtain this information:
Name: Title/Office -- —
Address: Phone:
City/State/Zip Email:
You may deliver the form to our office,fax(904)255-3433 or scan and email to
FOR OFFICIAL USE ONLY
lanas ancoi.fet or obyles@coi.nel Date received
Upon verification,you will be queued to receive the daily vote by mail request Username
information once the ballots are outbound.Ballots typically are mailed each
business day in varying quantities. Password
A username and password for access to Candidate File Distribution will be Date contacted
assigned and emailed to you.
You will be notified when the vote by mail request information becomes Call 904-255-3429 or 904-255-3416 if you need additional
available for each applicable election. assistance.