Iowa Admin. Code r. 721-21.11
Each voter who is required to vote a provisional ballot at the polls on election day shall be given a statement from the precinct election officials which shall be in substantially the following form:
Statement to Person Casting a Provisional Ballot
(To be completed by Precinct Official and given to Voter)
Voter's Name:___________________________________
Reason for Provisional Ballot (check all that apply):
[] Voter did not have proper identification (see "What you need to provide" below)
[] Absentee voter with no ballot to surrender
[] Voter was challenged by another registered voter Reason:____________________________________________
What you need to provide before your ballot will count:
[] Photo ID that has not expired and contains your name and picture
[] One of the following that has not expired: Iowa driver's license, out-of-state driver's license, non-driver ID, U.S. passport, U.S. military ID, ID card issued by an employer, student ID issued by Iowa high school or college
[] One of the following showing your name and current address: bank statement, paycheck, utility bill, property tax statement, residential lease, government check, or other government document
Deadline:_______a.m./p.m.,____________(date)
Mail or Deliver Evidence to:_________________, County Auditor
County Auditor Address:___________________________
______________________________________________
If proof of ID or residence is required, your provisional ballot may be counted if you bring a copy of the identification listed above to this precinct before the polls close today or to the county auditor at the above address by the deadline indicated above. If your ballot is not counted, you will be notified by mail of the reason why it was not counted.
Your right to vote will be reviewed by the Special Precinct Board. You have the right and are encouraged to make a written statement and submit additional written evidence to the Board supporting your qualifications as a registered voter.
____________________________ _______
Precinct Election Official's Signature Date
This rule is intended to implement Iowa Code section 49.81.
Iowa Admin. Code r. 721-21.11