(3) The Provisional Ballot Voter's Certificate and Affirmation shall be in substantially the following form:
STATE OF FLORIDA
COUNTY OF
I do solemnly swear (or affirm) that my name is ; that my date of birth is ; that I am registered and qualified to vote in County, Florida; that I am registered in the Party; that I am a qualified voter of the county; and that I have not voted in this election. I understand that if I commit any fraud in connection with voting, vote a fraudulent ballot, or vote more than once in an election, I can be convicted of a felony of the third degree and fined up to $5,000 and/or imprisoned for up to 5 years. Further, by providing my information below, I authorize the use of e-mail, text message, and telephone call for the limited purpose of signature and ballot validation.
(Printed Name of Voter)
(Signature of Voter)
(Current Residence Address)
(Current Mailing Address)
(City, State, Zip Code)
(Driver License Number or Last Four Digits of Social Security Number)
(E-Mail Address)
(Home Telephone Number)
(Mobile Telephone Number)
Sworn to and subscribed before me this day of, (year).
(Election Official)
Precinct # Ballot Style/Party Issued: