Poll Incident Report Form

Please fill out this form clearly, describe the incident with enough information so we can better understand your complaint. The information you provide will remain confidential during the investigation and verification of the incident.

* -indicates required field

Voter Information

Name

Address

City

State

Phone Number

Email

Poll Location Information

County

City

State

Zipcode

Precinct Number

Polling Place Name

Name of poll employee/elected official involved

Date/Time

Date and Time of Incident

Select All Applicable Issues

 Poll hours incorrect Identification problems (ie: wrongly asked for identification) Voter challenged (ie: attire/unpaid fines/foreclosure/criminal record) Denied provisional ballot Immigration issue (ie: immigration offer present/asked for proof of citizenship) Voter sent to wrong precinct Electronic equipment problems Denied access because of disability Voter registered incorrectly

Description

Description of Incident

Description of Action Taken, if Any