Free 52410.pdf - Indiana

AFFIDAVIT OF COUNTY ELECTION BOARD OR ABSENTEE VOTER BOARD MEMBER CHALLENGING ABSENTEE BALLOT APPLICATION
State Form 52410 (R / 9-07) Indiana Election Commission (IC 3-11-4-18.5)

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(ABS-20)

INSTRUCTIONS: After an absentee ballot application has been received by a county election board, a member of the county election board (or a member of an absentee voter board, in counties where those boards are appointed), may file an affidavit challenging the absentee ballot application. The county election board shall promptly conduct a hearing on this matter, and determine whether the absentee ballot application should be approved or denied. The county election board may also refer the matter to the prosecuting attorney.

INFORMATION OF COUNTY ELECTION BOARD OR ABSENTEE VOTER BOARD MEMBER
Name (please print) Title (check one) County Election Board Member Absentee Voter Board Member

Facts Known or Believed by Individual Filing Affidavit (check one)

Absentee ballot applicant is not a voter of the precinct. Absentee ballot application contains a false statement. Absentee ballot application has not been executed or filed in accordance with Indiana or federal law.
Brief statement of the facts known or believed by the individual filing this challenge affidavit, detailing information checked above: ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________

STATEMENT OF COUNTY ELECTION BOARD OR ABSENTEE VOTER BOARD MEMBER I swear or affirm under the penalties of perjury that all of the information set forth on this affidavit is true to the best of my knowledge and belief.
Signature Date signed (month, day, year) ____________/______________/______________

A person who makes a false, material statement under oath or affirmation, knowing the statement to be false or not believing it to be true commits perjury, a Class D felony, which is punishable by imprisonment for a term of up to three years, a fine of $10,000 or both. (Indiana Code 35-44-2-1)

Penalty for Perjury: