S.D. Admin. R. 5:02:05:22
The provisional ballot envelope shall be blue and in the following form:
Voter's Affirmation for a Provisional Ballot
My voter registration was completed on or about the following date and was left with the following person or agency for delivery to the county auditor: ____________________________
__________________________________________________________________________. My name is _________________________, I reside at ____________________________, my mailing address is _______________________________, my date of birth is ___________, my South Dakota driver license number is ___________, my daytime telephone number is ___________ and my evening telephone number is ___________. If I do not have a South Dakota driver license the last four digits of my social security number are ______.
I understand if the election authority determines that I am not registered in this precinct and therefore not eligible to vote in this precinct, my vote will not be counted. I further understand that my vote may not be secret if only one provisional ballot is cast in the precinct. I declare and affirm under penalty of perjury that I registered and am eligible to vote in this precinct.
________________________________________ ___________________
Signature of Voter Date
To be completed by a precinct election worker:
Precinct number _____________ Type of ballot provided to voter ______________
__________________________________
Signature of precinct worker
S.D. Admin. R. 5:02:05:22
General Authority: SDCL 12-18-40.
Law Implemented: SDCL 12-18-40.