Keane - Vote-by-Mail Data Request - 9-6-22 'Of Ft N
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�Q s4:. ,, VOTE BY MAIL DATA
' •9' 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)
rg Candidate who has filed qualification papers & is opposed in an upcoming election (Race:Age,-(-L&4 Atm' ce.a.f- 'L
Election Cycle: 20 2-2- ( c^-e � / Data requested: ^II Parties oDemocrat Republican oOther
Please Print I /
Name: h r�9 0 n-e_ Title/Office CP- • -le `fidr /f'lc5lcr Cee,j--
Street Address: y-6 .b . Phone: 90 7 52 (
City/State/Zip /4.4-- ,-5-,`_‘ ( L f EL32253 Email: �� SCG , (ter ye ri r)/.5
I affirm that I a per ,..a ' ed by Section 101.62(3), Florida Statutes, to acquire vote by mail information.
SIGNATURE 0' PERSON REQUESTING INFORMATION DA°tE
The f regoing instrument was acknowledged before me
this day of J f eih.her'- , 202:2- ,by •
Si e- ,who is
personal' known or who presented DONNAL.BARTLE
/ as identification.
�x] • MY COMMISSION#HH 085656
ff •'• � . ;.
. ;�o EXPIRES:May 14,2025
Notary Name: Do .,a Z, Bonded Thru Notary Public underwnters
Notary Signature: OOzvn..a ✓/�)L�i}�,(��, �w_..r'
Commission Expiration Date: 5/i'//Z02S
p{I also designate the following person acting on my behalf to receive and use my username and password to obtain this information:
Name: tf icL Paz 6e r/A •• Title/Office CGn.Pci � 41.<.t 4 at•
Address: g 3o ,-(,4 (1/ / -3! 7 Phone: 2J•2 7(9 C(3 2 2_
City/State/Zip P"^ -K- CAG I , it" 32° mail: QG 6)Sec2^-Pc r S fors• O
You may deliver the form to our office,fax(904)255-3433 or scan and email to FOR OFFICIAL USE ONLY
lanas(7a col.net or bbvles icol.net
Date received
Upon verification,you will be queued to receive the daily vote by mail request
information once the ballots are outbound.Ballots typically are mailed each Username
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.