Case 2:13-cv-00193 Document 737-5 Filed in TXSD on 11/17/14

Transcripción

Case 2:13-cv-00193 Document 737-5 Filed in TXSD on 11/17/14 Page 1 of 83
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310784032
Affidavit of Provisional Voter
Declaracion Jurada de Votante Provisional I Ban Chlrl1g TM Cua Cir Tri T?m Thai I Wn~iit~J!:~ii
TO BE COMPLETED BY VOTER: I am a registered voter of this po litical subdiv ision and in the precinct in which I'm allcmpting to vote and have not .a lready vo ted in this election (either in person or by mail) . I am a resident of
this political subdivision, have not been finully convicted ofa felony or if a felon, I have completed nil of my punishment including any term ofinc~rceration, parole, supervis ion, per iod ofpro botion. or t have been pardoned. I have
not been determiner\ hy 3 fin<~ I judgment 1lf a court exercising probate jurisdiction to be totally mentally incapac itated or partially mentally incapacitated without tht: right to vote. I undcr.aand that giving false information under o:Hh
is a misdemeanor, and I understand that it is a felony of the 2nd degree to vote in an election for which I know I am not eligible.
(PARA QUE El VOTANTE LO LLENE: Estoy in:;;crito como votantc en csta subd ivisi6n politica yen cl prccinto en cual estoy intcntando a votary aun no he votado en csta clccciOn (en persona o por corrco). Soy rcsidcntc de
esta subdiv isiOn politico., no he s ido dcfinitivamcntc dcclarndo culpable de un dclito grave o si soy el autor de un del ito grave, he cump lido todn mi condcno. inclusive cl pcriodo de cnearcelamicnto, Ia libcrtad condiciona l, Ia libcrtad
supcrv is:J da. Ia libcrt:u.l vigiladJ, o he sido indultado. No me han dctcrminad o por unjuicio final de una cone de Ia lcgalizaciOn de un testamento, scr totalmcntc incapaci tado mcntalmcntc o parci:~ l mentc in c.1pacitado sin el Ucrccho de
vo tar . Enticndo que dar infornl:leiOn falsa bajo juramenta es un del ito me nor y tambiCn ent icnUo que cs un de lito grove de 2dn grndn volar en una clccciO n sabie ndo que no cumplo con los rcquisitos necCS<~rius.) (DU'Q'C HOAN TAT
BOI clr THI: T6i hl clr lri dU ghi danh b6 phiCu t~i phan khu chinh tri dja phuang n<ly va trong ph:in khu rna t6i cOy djnh bO phi~u vit chua b6 phitu trong cu¢~.: bAu cti nt.y (kE c:i dich thfin b6 phi~u hay b6 phi~u b~ng thu). TOi Cli
ngv IQi phdn khu chinh tri d!a phuong n:i y. t6i ho:'ln toiln kh6ng bi J.a~t trong tOi ho~c n~u l:i nguOi ph;;un lrQng tVi. tUi da huil.n thilnh h~t moi hinh ph<.~t. b~o g6m thOi h~n tU, an !reo, qutln ch~, thOi k)' thLr tholch. ho~c da du(JI.: tha . Ph:in
quy~t cu6i cUng cUa tOa fin kb6ng tuyi:n b6 r~ng t6i l:i ngu cJi m&t ho:ln toimniing h,rc v~ m~tt5.m th~n hay m&t m¢1 ph&n nii.ng l ~,rc dc3 t6 i cO quy~n duQc b6 phi~u. T6i hic3u dng khai man khi tuyCn th¢ sC bj ph~m khinh tQi , v;i t6i hiiu
r~ng n~u bi> phi~u <rang m<)1 cu<)c b.lu Clr m; loi bii 1 t; oninh kh6ng h<) i du diBu ki~n. loi so bi coi t; plwm trQng IQi dp d<) 2.) EIJil![~IJU'~: :.j;:)d"UtiJ&iZ;I'Ji~P'IZ~ii!;il!l'.\0, :.j;:},#Ji!:~jj_i;\j*:(fUt:);jj!l!lcp!l!:~# (¥Jl§jjl(ffiF>b'f
IQ~) • :.t;:},~Jltil&isi'JiQJ;ZJi!l~ · tU~JI'.'I'lill'll'iffilt<ll<HlEml · ~~DIH!181'l!!.ll!l · !§.Pfi'l'l!BJFJ · B!1:!iWiilil: · l>:lf1l · Wiitl' · t!'lil'J~E.IJI~'ii:ll!~ell'iil!<.\t • :<$:},1::t*=lfijg~!Oil.l!it;/i1QHti'U£~*!11¢7'i:~;,x;ffliiBW
5Hii1Jiffi!!i\JQW!llli • :;ji:},I!JlH~:J[GtlitQ~H:ct:i'ii.RJe,fl!l/ll 'l>jiQT~~tE'l'lfli§C'."ffffi:i'itM'J~i1LT1Iil!l!l<P!l!l\'ll>=tillfiml •
last Name {Apellido) {HQ) (id)
first Name (Nombre) (Ten) (t,)
Mid dle Name (if any) {Segundo nombre (si tiene)
en dem {neu c6) <Pre~:!'; ( '6'1'f l
Former Name (Nombre anterior)
{Ten cii) (\\I fll:!';)
Residence Address: Street Address and Apartment Number, City, State, ilnd ZIP. If none, describe where you live (Do not include PO Box, Rural Rt. or business address) {Oomicilio: calle y nUmero de apartamento, Ciudad, Estado, y
COdigo Postal: A falta de estos datos, describa Ia local idad de su residencia. (No in cluya el apartado de correos, camino rural, ni direcd6n comercia l.)) (Oia chi ell' trU : Ten dU'bng v3 sO Phbng, Th3nh PhO, Tieu Bang, va M3 Buu oien.
tfj:l';Jllilll:lU~Iil'lfl
Neu kh6ng c6, xin dien Ia nai quy vi elf ngy (Kh6ng dvqc de dja chi H\ip Thv, Dja Chi Dvong lang hojc Dja Chi Thvang Moil) @f±lltlll: :
· iii ·
~HU!fll;lfLg'lfl• Jm~ijt'l'f
· fu'/if!lllillllll@flllt!li Ol'lo/JI!l['il
!f.l i.<Hil'lfl~!J · :ill91·lf3!.!i!·~flll~~i!lj~,~lti!JII:)
Mailing Address: City, State, and ZIP. If mail caimot be delivered to your residence address. (Di recci6n postal:
Ciudad, Estado y C6digo Postal, si no es posible entregarle correspondencia en su domicilio) . (Oja Chi Glri Thl1:
Thanh Ph6, T iE~u Bang, va Ma Bllu DiCn. NCu kh6ng thC chuyen thll' t&i dlt1 chi cu ngv cUa qu'(vj.) !ffi~i~ij}: : rti ·
iHlMr.i!ll~&~
Gender: {Optional) {Sexo {Optative)) Gibi tlnh:(Kh6ng
b~l
Thang, Ngay, Nam) ill~ 8 Wl : fj · 8 · lf-
• ilD!IH<fl~'r!ii\ii!;iiiil\!&<il"J011lti!IJI: •
Male D
Female~
(Mujcr)( Nfr)(3l;)
(Hombre)(Nam)(lfl)
Check appropriate box: Marque cl
cuatlro upropiudo: D:inh ddu vf10 0
lhich hgp tlilll101Jt~r*H!l•J1J :
TX Driver's license No. or Perso na ii.D. No. (Issued by TX OPS) NUmero de
su licencia de conducir de Texas ode su Cfdula de ldentidad expedida por
el Departamento de Seguridad Publica de Texas). SO sang liii Xe cUa tieu
b .T
h I ' 10 a h" {d B. A T
l o·
I'' b
T
.
Date of Birth: Month, Day, Year (Fecha de
nacim ie nto: mes, dia, aiio)(Ngay thcing n~m sanh:
bu<)c jifllf: ( Dfljl;,x;"f'IJ()
Social Security No. (last 4 digits required if you do not have a driver's license or I. D. number) NUmero de
Seguro Socia l. (Sino tiene licencia de conducir ni identificaci6n personal, se requiere los Ultimos 4 nUmeros de
su seguro social) SO An Sinh xa HQi (4 sO cu6i cUa sO An Sinh xa HQi c'an phit i c6 neu qu'( vj khOng cO sO bAng
JHt'li'~'l,~li!!l
tat xe hole solD ca nhan)
( Jm!lt'"''~1'll'im~8ll;,x;fiD},!J-fBi!!'lllli!'l
'i'i!l!~l±g;;-t®:!Jt
ARE YOU A UNITED
STATES CITIZEN?
(;,SOY CIUDADANO/A DE LOS
ESTADOS UNIDOS'!) .(QUY V)
c6 PHAI tA CONG DAN HOA
KY KHONG?J !.1!i>c!Xellll0B.'U.m?
9Qves
D
(Si)(C6)()i1c)
No
(No){Kh6ng)(6)
•
0
•
Texas/Cedula de identidad personal de Texas ni un Numero de
Segura Social.) ( T6i ch11a he di1Q'C cay bang lai xe cua Texas/so
tD ca nhan ho~c so An Sinh Xa Hoi.) 'l'!W1~1 TX ~~~ll:ill!w.iliRb~/
ffklA#f7HlHt!11i!'lWZH~:ii::i:lt'!li'.!j"
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TO BE COMPLETED BY THE ELECTION JUDGE
Date of Election Fecho de Ia Elecci6n
Ngay B5u Cil illl!l 8 WJ
I
I have not been issued a TX driver's license/
personal identification number or Social Security
Number. INa me han expedido una licencia de conducir de
Precinct No. where voted
HomePCT
Counry Clerk Use ONLY
PCT
Voter Registrar Use ONLY
PCT
03 \o I
NUm. de Prednto·lugar de votaci6 n/Phan Khu nai dii B'au Clt S6/UB~.!lii
'lfl. !Jll\'illti!\1
Precinct No. where registeredQ
3 (o
I
0301
NUm. de Prec into-inscrito pa ra votar/Phan Khu nO'i da ghi danh sO/in~
t.\ii'l!C.
Type of Election Tipo de ElecciOn
Hinh Thlrc sau Clt li!fflM~
:ll:ii~Jtl;!li
TO BE COMPLETED BY THE COUNTY VOTER REGISTRAR
FOR STATUS:
Authority Conducting Election Autoridad Administrondo Ia Elecci6n
CO' Quan Thom Quyen
nen H6nh Bou Cv :Efifif!i'Jfi/1/H
tkn ·1~
Cou..V1 ry
1, the voter registrar/deputy registrar, did research the records of my office and
the following conclusion(s) wos made:
~~~::h~~o~~.~i~Ln~n ~ ~vi!na~ai ;S~b ~v~e
voter's signature area. The Provisional Ballot Stub is generated from the JBc.)
FOR VOTERS WHO DID NOT PRESENT ACCEPTABLE PHOTO /DENT/FICA TION
AT THE POLLING PLACE
Voter presented acceptable form of identification within 6 days of
1.
election doy.
VOTER PRESENTED ACCEPTABLE FORM OF IDENTIFICATION
1.
~ed
1!/fgs
~o
to present acceptable form of identification or voter
certificate with exemption.
2.
Voter not on list of registered voters.
3.
Voter not on list, registered in another precinct.
4.
5.
Voter on list of people who voted early by mail, and voter has not
cancelled mail ballot application.
Voting after 7:00P.M. due to court order.
2.
Vater met disability exemption within 6 days of election doy.
3.
Voter executed religious objection affidavit within 6 days of election day.
4.
Voter executed natural disaster affidavit within 6 days of election doy.
5.
\7"
·Voter did not satisfy identification or affidavit requirements, listed in
categories 1-4 above, within 6 days of election day.
FOR VOTERS WHO VOTED PROV/SIONALL Y FOR OTHER REASONS
6.
Not o registered voter or registration not effective in time for this
election.
7.
Registered to vote, erroneously listed in wrong precinct
8.
Registered to vote in a different precinct within the county.
Q
Jnfnrmntinn nn fii P inrlirntinn nn nlirnnt rnmni&Jt-Prl n tmt&Jr rPnictrn~inn
PR
1111111111111111111111111111111111111111111111111111111
310784041
Declaraci6n Jurada de Votante Provisional I Ban Chilng Th~ Cua Cir Tri T~m Thai I !mB~il~~~-
TO BE COi\1
BY VOTER: 1 am a reg istered voter of this pol itical subdivis ion and in the precinct in which I' m atlcmpting to vote and h:Jve not already vo ted in th is election (either in person or by ma il). I am
t1
this po litical subdivi!>ion, have not been finally conv icted of a felony or if a felon, I have completed :JJI of my punishment inc luding any term of inr.:arceration, parole, supervision, period of probation, or I have been pardoned. I h:1vc
not been determ ined by u final judgment of a court c.xcrcising probate jurisdiction to be to tally mentally incapacitated or partially mentally incapacitated without the right to vote. l unders tand that giving false informa tion under oath
is a misdemeanor, and I understand that it is a felony of the 2nd degree to vote in an elect ion fo r which I know I am not eligible.
(P.-lRA QUE EL VOTANTE LO LLENE: Estoy inscrito como votantc en C$13 subdiv isiOn politica yen cl precinto en cual cstoy intcntando a votur y aun no he votado en esta elccci6n (en persona o por correo). Soy res idcntc de
es ta subdi\'isiOn politica, no he sitlo dclinitivamcntc dcclaratlo culpable dc un del ito grav~: o si soy cl au tor de un de lito grove, he cumplido toda mi condcna inclusive cl perlodo de cncarcclam ientn,la libcr1ad condic ional, Ia libcrtad
supcrvisada. Ia Iibert ad vigilndu. o he sido indultudo. No me han dctcrm inadn pnr un juicio fina l de tma corte de Ia lc::gali7.aei6n de un testa mento, sc r totalmcntc incapacitado mcn talmcntc o parcial mente incapacitado sin cl dcrecho de
votu r. Enticndo qtJc dm informaciOn falsa bajo juramenta cs un de lito mcnor y tambiC n cnticndo que cs un de lito grave de 2do grado volar en una clccci6n s"bicndo.quc no cump lo con Ius requ isites neccs<trios.) (OU"QC IIOAN TAT
B(J'I ClrTRI: TO i 1~ clr tri d<i. ghi danh bO phiCu t;;• i phfln khu ch inh tr i dja phuong nay vil 1rong ph~n khu mfl t6i c6 y din h b6 ph i~ u vil chLta bO ph it u 1rong cuOc b5u ell n<iy (k~ c:i dich 1hfi n b6 phiC:u hay b6 phiEu b& ng thu). T6i w
ngv l:jli ph<ln khu chinh tr! dja phuong n:'•y, t6 i hoiln toim kh6ng bj k~t tn;mg t¢i ho~c n~u lil ngucJi ph1,1m tn;m~ t¢i. t6i dii hofln th.lnh h~trnQi hinh ph(lt, bao g6 m thcJi hi;l n tU, an I reo, qu:i.n ch6 , thOi kY thU th:i.ch. ho~c dil duqc tha. Phiin
quyt t t:u6i cUng t:Ua lOa t'm kh6ng tuyCn b~ rang ltli Iii ngui:r i m~t hoO:n IOilll niing lvc vC 111~1 tiim thf.n hay mfit mOt phtn n~ng lvc d~ t6i c6 quy~n duqc b6 phiCu. T6i hitu dng khai man khi tuyCn th~ sC bj phi)m khinh tQi, va t6i hi~u
,jng nEu b6 phiiu 1mng m<)1 cu<)c b6u cu ma 16i bil1\a min h khong h<)i du diiu kicn.16 i sc bi coi Ia ph'm ''9ng l<)i dp d<) 2.) dlillB':lJHll: ;t;:A.l:lilti&illf~ll>r"JL.g;i!;ill"". :<I'A.'P!~t;;!iil.t'j;t-:(EJlt:);:jjl!il'l>tll:~ (¥J!Ei~\1!FII~'t
tltl'li> • ;t;:A.J.olttif.'< i15t'i~L.F.5~ · t:e:il,f!'lm'M·m:wffij11<fimli':w · ~~nl~l'im'~lfl:w · I!:!M:f'f!!\lioJ · EJ.ttlliUi'l ·
ll.i'm' · mif!J~EI£jl:7i'.l!>•tel!<n'<!£ • :¥A.t:e*11<irl'ill<iitltitlf!Qml:1Ef!'J"ll~ie:t~lll\llltlt
9<!/C:!JffiJ!i\\lll:~.~fj~ • *J.'lll if.l]!fS'i.t:tli!IJ \ 1-'fn~iRP.lf.J!:w · 11!TP>f:ffB
fl i:f1Eic'FFF&i."it:;(f:Jt;l;5tTifilllll't'tll:lili1.0::.tJllR;til·
mm ·
(Apellido) (Hoi (ill.)
Name (if any) (Seg undo nombre (.si tiene)
dem (neu c6) 'l>fo~i'. ( :151'l)
Na me (Nombre ante rior)
cO) (1\)I!J;g)
~e__
Res idence Address: Stree t Address an d Apartment Number, City, State, and ZIP. If non e, describe where you live (Do not include PO Box, Ru ral Rl. or business add re ss ) (Domicilio: calle v nUmero de aparta mento, Ci udad, Estado, y
C6digo Postal: A (alt a de estos datos, describa Ia loca lidad de su residenc ia. (No incl uya el apartado de correos, camino rural, ni di recci6n comercia l.)) (Oia chi elf trU: Ten dl!Ctng va sO PhOng, Thanh PhO, neu Bang, va Ma Bv u Oi~n .
Neu khong c6, xin di~n ta ncri quy vj w ngu jKh6ng dvqc de dia chi Hop Thv, Dia Chi Dvimg Lang h o~c Dja Chi Thv crng M~ i )) @l£1\t!Jl: : f!ji',l\tl.il:HJ01il11!1 • ill · i·I·('I!Ji[q:;~lilij~R • ~O*i!Hl' • ii'ia1~iffi~518Jl@j1J~!!,l; ( iil'lo/JJRiJil\
~~-
)
Sta te, and ZIP. lf mail canno t be de livered to you r residence add ress. (OirecciOn posta l:
Ciudad, Es tado y C6digo Pos tal, si noes posible entrcgarle correspondenda en su domicilio). (Oia Chi Glti Tht.t :
Thilnh PhO, TiE!u Bang, v.a Mi"i Bvu Di(!n. Neu kh6ng th€ chuy€n th u t&i dia chi ell ngv cUa quy vi.) !f:~~fti!.hl : rtl ·
Ge nder: (Optional) (Sexo (Opta t ive)) Gi6i tinh:(Kh6ng
b~t bu<)c !18'1: ( OJ!Jl~'FIJ-i)
Tha ng, Ngly, Nam) :±J~ EJ Wl
iHi!l>i!lli!Eilh'llil • ~Dl!!iiF>*i'~i£itif!G.:rt:JF.5!1lltl.J!: •
Chec k appropriate box:
cuad ro apropiado: E>:inh d&u v:io 6
lhich hqp :(Ejj!j·IJtiJtt\i*i!DIJt] :
TX Drive r's License No. or Personaii.D. No. {Issued by TX DPS) NUme ro de
su lice ncia de con ducir de Texas ode su c edula de lde ntidad expe dida por
el Departame nto de Seguridad Publica de Texas). SO BAng L3i Xe cUa tieu
Texas ho~c sO 10 c3 nh3n (do 8 0 An Toi:J n lao
tle'u bang Texas
Date of Birth: Month, Day, Yea r (Fecha de
naci miento: mes, dia, ai\o)(Ngc'ly th.ing na m sanh :
Male 0
Female~
jHombre)(Nam)(!/l)
(M ujcr)( Nfr)(:9;)
: Fl · El · JJO
Social Security No. (last 4 digits req uired if you do not have a d rive r's license or I. D. numbe r) NUme ro de
Segura Social. (Sino tiene licenda de conduci r ni iden tifi caci6n personal, se requiere los Ulti mos 4 nU meros de
su seg uro social) 50 An Sinh xa HOi (4 sO cu6i cUa sO An Sin h xa HOi din pha i c6 neu quVvi kh6ng c6 sO bang
'" xe hoic so lD ca
Hftt:IC:*:'llt~
ARE YOU A UN ITED
STATES CITIZEN?
EST ADOS UNIDOS'I) (QUY V !
C6 PHA I LA C6NG DAN HOA
KYz::l!~;~~::mo
(Sill C6)(:f£)
Dare of Elect ion Fecho de Ia Eleccidn
Ngav Bau cil
ill!!! EJ Wl
Home Per
County Cler k Use ONL Y
Per
CERT/VUIO
Voter Re gistrar Use ONL Y
Per
03 ~1
Precin ct No. where voted
Nlrm. de Precinto-lug ar de vo taci6n/P h5n Khu na i da Bilu Clt 56/illQl;"~
~-tlt~Jttl!ll
Precinct No. where registered ____,0"'--3
=-...:(=--'1'---,...p
NUm. de Precinto-inscrit o pa ra vota r/Phan Khu nal d.J ghi da nh sO/ill~
~>I'!.
FOR STATUS:
Elecci6n
I, the voter registrar/ deputy registrar, did research the records of m y office and
the following conclusion(s) was made:
BALLOTCODE:
J0-2FL/SJ5_J
(Writ e in the Ballot Code, it is found on the Provisional Ballot Stub above t he
vot er's signature area. The Provisional Ba llot Stub is generated from t he JBC.)
FOR VOTERS WHO DID NOT PRESENT ACCEPTA BLE PHOTO /DENT/FICA T/ON
1.
Voter presented acceptable fo rm of identification within 6 days of
election day.
1.
~ pce~ot~~c:p.,bl'
to
to em of=
'"" oc .otec
certificat e with exemption .
2.
Voter met disability exemption within 6 da ys of election day.
3.
Vo ter executed religious objection affidavit within 6 da ys of election da y.
4.
Voter executed natural disas ter affidavit within 6 days of election da y.
S.
_L_
Voter did nat satisfr identification or affida vit requirements, listed in
ca tegories 1-4 above, within 6 da ys of election day.
2.
Vote r not on li st of regist ered vo t ers.
3.
Voter not on list, regi ste red in anoth er pre cin ct.
4.
5.
FOR VOTERS WHO VOTED PROVISIONALLY FOR OTHER REASONS
6.
Not a registered voter or registration not effective in time for this
election.
Vote r on list of peopl e w ho vot ed ea rly by mai l, and voter ha s not
cancell ed mail ballot application .
7.
Registered to vo te, erroneously lis ted in wrong precinct.
Votin g aft er 7:00P.M . due to cou rt order.
8.
Regis tered to vote in o different precinct within the county.
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IIIII II IIIII IIIII 111111111111111 11111 11111 1111111111111
310784096
Affidavit ofProvisional Voter
Declaraci6n Jurada de Votante Provisional I Ban Chll'ng Th~ Cua Cir Tri·T<,\m Thai I lm~il!l~JUi~il
TO BE COMPLETED BY VOTER : I am a rcgis1ercd vo1cr of this polilical subdivision and in the precinct in which I'm attcmpling 10 vole Dnd have not already voted in this cleclion (either in person or by mail). I am a rcsidcnl of
!his po liticul subdivision, have no1 been finally convicted of a felony or if a felon, I have complc!ed all of my punishment inc luding any term of incarcerat ion, parole, supervision, period of probat ion, or I have been pardoned. I have
1101 been determined by a final judgmcnl of a court exercising probate jurisdiclion to be to! ally mentally incapacilated or partia lly mentally incapacitat ed without the right to vote. I understanc1 that giving false inform;Jtion under oat h
is o misdemeanor, and I understand that it i.s n felony of the 2nd degree to vote in :m ekction for which I know I am not eligible.
(PARA QUE EL VOTANTE LO LLENE: Estoy inscrito como vo tantc en cstn subdiv i$i6n politicu yen cl precinto en curd cstoy intc ntando a volar y aun no he vo tado en csta elccci6n (en persona o por corrco). Soyrcsidcntc de
cstn suhdivisi6n politica, no he sido definit ivnmcnte dcelaradn cu lrnhlc de un del ito grave o si soy c l nutor de un de lito grave, he cumplido toda mi condena inclus ive el rcriudo de cncarcclamicnto,ln libcrtad condicionul, In libcrtnd
supervis:.~dn. In libcrtad vigilada. n he sid o indu ltndo. No me han dctcrminado por un juicio linn! de una cone de Ia lcgc.d izilc i6n de un testamento. ser totalrncntc incopacitado mcntalmcntc o parcialmcntc incap:1citado sin ct dcrccho de
vo!r~r. F..~Hicndo que dar informaciOn falsa bajo juramenta cs un de lit o ~1cnor y tambiCn cnlicndo que cs un del ito grave de 2do gra~o volar en una c_l~cciOn sabiend~ que no t:u~plo con los requis110~ ncccsarios.)_ (Of:fQC IIOAN TAT
BOI cu· TRI: T6i 13 clr tri dri ghi danh b6 phiCu t:;ti ph:in khu ch inh tq dja phllong n:iy vil lrong phiin khu m:il6i c6 Ydinh bO phit:u v:l chlla b6 phu!u trong cuQc biiu elr n:ly (kC ell d(ch thin b6 phiCu hay bO rh iCu b~ng tint). TOi Ctl
ng1,1 t\li phiin khu chinh tr! d!a phucmg nily. t6i hoim to:in kh6ng bj k6t trQng t¢ i ho~c nCu l:i ngLJOi ph~m trc;mg tQi, t6i d3 hoiln th:inh h~t mQi hinh ph~t. bao g6m thOi h;;m tU, tin tree, qu:in ch~. thOi kY lhlr th.ich. ho~c d5 duQ'C tha. Ph.in
qllY~l cu6 i cUng cUa tOa .in kh6ng tuyen b6 r:lng t6i 1:'1 ngu6'i mAt ho~n to:in nang 1\rc v~ m~t tiim thfin ha y m~t tnQt ph~n n~ng h,n: d6 t6 i cO quy~n dU"Q"C bO phiEu. T6i hi~u rfmg khni man khi tu yCn th~ sC bj ph\lm khinh tQi. v3 t6i hitu
r~ng ntu b6 phi&u trong mQt cu(>c b.iu cir m:l t6i bi~t 13 minh kh6ng hOi dU ditu ki~n.t6i sC bj coi Iii ph;;!m trqng tQi dp dQ 2.) EtlU]~tjl~: ~A!\lltt&~f:i~l&ytqZ:~·;~ill~. ~A1§ffl.M{.§_f'51$:lf]tt:XllX!flcf"lt~~~~ (lfH3~[1fl*
llHMl • ~'.A.~Jlti!Jl>sf~ii>Z/i!';l\'; · i~t5f-IWil'i'flfi;Jlifl11&flW!lE~Jl · !i<~lli!EI'lllll'I'H!Hc · !E!fli'i'flP.IVI · §~t'l:!i'; ·
~.frill'· !!llf!Jl<JE.Ili:\'t7'Gll!li'<El&nx!e • :;t,;.A.~*l&i1liJi!~ill>l:Ji!jj'H¥~lEfllll11$7'G3':!£llfllijil!
9ifffi:!Jnn!!l\lll:i'IH'i ll·
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om·
• lti7mttBJll:!IEIC.'FB~l:'Hllil'lti'l>lt"fttilll!l'1'1l!:illl~=fll!fm •
l ast Name {Apellido) {HQ) (itt)
First Name{Nombre)(Ten)
(i:\)
Middle Name (if any) {Segundo nombre (si tiene)
en dom fneu co)
'1'ro1;g ( :i!i'R)
{Ten cu)
('ill flli:\1
~tMr-~
Residence Address: Street Address and Apartment Number, City, State, and ZIP. If none. describe where you live (Do not include PO Box. Rural Rt. or business address) (Domicilio: calle y nUmero de apartamento, Ciudad, Estado, y
COdlgo Postal: A falta de estos datos, describa Ia localidad de su residencia. (No inc luya el apartado de correos, camino rural, ni direcci6n comercial.)) (O(a ch i cU' trU: Ten dvb'ng va s6 PhOne, Th.lnh Ph6, Tieu Bang, va M;i BU'u Oi~n.
~~~~~6, :~~~~~r,~;~~~;~~ 'Z1{~ja 'MT;;hiO~~ holcOja ChiTh~~~~~;n~. rn '11"oo5~. ~ot~m;~B)l@(±~~j ( m~mffill
Mailing Address: City, State, and ZIP. If mail cannot be delivered to your residence: address. (Oire:cci6n postal:
Ciudad, Estado y C6digo Postal, si no es posible entregarle: correspondencia en su domicilio). (Oia Chi Gtii Thv:
Thanh Phd', Tieu Bane. vil M5 Bvu Di¢n. Ne"u khOng the chuyen thlf t&i dja chi cu ngv cUa qu'f vi.) [rJH!)-i{tft : rti ·
HHtlffi1lJ!iffii)l,~
Gender: (Optional) (Sexo (Optative)) Gi&i tfnh:(Kh6ng
b5t bu¢c tl~~: ( "ii)'IJ(li'('fi.IO
• ~O!iQ!rJllli!!l\iti.lli!fi.'!f:A"J@I±Jl!!lli: •
C,)(o jill~ S+ ~~~'\\K"/7~
Check appropriate box: Marque c l
CU<Jdro ilpropiado: f><inh d.iu VJo Q
thich h\11) ttim1ii:nilll*ifli111:J :
ARE YOU A UNITED
STATES CITIZEN?
ESTADOS U
OS'!) (QUY V!
C6 PHAI
C6NG OAN HOA
?) !J!:Jll:jli~ij:'Gf\;0%?
D
(Si)(C6)(:fll:)
No
{No)(Khong)(B)
TX Driver's License No. or Personal t.O. No. (Issued by TX OPS) NUmero de
su licencia de conducir de Texas ode su cedula de ldentidad elepedida par
el Departamento de Seguridad Publica de Texas). S6 sang L;ii Xe cUa tieu
bang Texas hoijc sO tO ca nhan (do BO An To~ n lao OQng tieu bang Texas
.
Male D
{Hombre)(Nam)(Jij)
Number. (No me han expedido una licencia de conducir de
Segura Social.) ( T6i chtta he dttc;tc cap bang lai xe cua Texas/so
ID ca nhan ho~c so· An Sinh Xa Hoi.) '!ti~1'J TX ~~¥J\!m5difil!j/
•
aau Cctll!lf! 8 Wl
(Mujcr)( Nfr)(:j(:)
so
.
. . .
..
..
. .. . ..
~
X
Date of Election Fecha de Ia £/ecciOn
Female%--
Social Security No. (last 4 digits required if you do not have a driver's license or 1.0. number) NUmero de
Segura Social. (Sino tiene licencia de condudr ni ident ificaci6n personal, se requiere los Uhimos 4 nt.imeros de
su seguro social) 56 An Sinh xa HOi {4 s6 cu61 cUa sO An Sinh X5 HQi c"an ph3i c6 ne'u quy vi kh6ng c6 sO bang
lai xc hoac
ID ca nhan)
i±!t'i<i-W!Ii'li ( ~OJI!.'!f:>J!'i'f!!l!\Ttll!w.li'<OO.A.~I7lafl'lflli'li · ll'llle!JliU'<C-Fia!J'<
.
(~)._!J-(7fi;If9}1fil!j~fi tt'ti.':i:$'ilill)
Ngay
nacimiento: mes, dia, ano)(Ngily thang nam sanh;
Thang, Ngay, Nam) Wg:13)1)J: fj · 13 · Jf
HomePCT
County Clerk Use ONLY
PCT
3 l,p )
NUm. de Precinto·lugar de vot aci6n/Phan Khu noi da BJu Clt SO/ill~~~
'l}(. ll!:~~Jl!!,T~
PCT
·3'-fo=-_,\__=
Precinct No. whe re registered ___
NUm. de Precinto-inscrito para votar/Ph<in Khu nai d3 ghi danh
!li~.
Hlnh Thuc
Type of Election Tipa de flecci6n
Bau Cit
il!l!!lilll!'i
sO/iR~
:'IHcltM\1
FOR STATUS:
Authority Conducting Election Autaridad Administrondo Ia Efecci6n
CO' Quon Thorn Quyen nen Hanh Bou Cti' 3£/iJjfff*l.lf/Pf
I, the voter registrar/deputy registrar, did research the records of my office and
BALLOT CODE:
Lo
S ~ !d.. .k l
k 1_
(Write in the Ballot Code, it is found on the Provisional Ballot Stub above the
voter's signature area. The Provisional Ballot Stub is generated from the JBC.)
FOR VOTERS WHO DID NOT PRESENT ACCEPTABLE PHOTO IDENTIFICATION
1.
election day.
DYES
1.
~d to present acceptable form of identification or voter
2.
3.
4.
5.
2.
Voter met disability exemption within 6 days of election day.
3.
Vater executed religious objection affidavit within 6 days of election day.
4. _ _
Voter executed natural disaster affidavit within 6 days of election day.
5.
Z
Voter did not satisfy identification or affidavit requirements, listed in
categories 1·4 above, within 6 days of election day.
6.
election.
7.
Registered to vote, erroneously listed in wrong precinct.
8.
9.
Information on file indicatinq applicant completed a voter reaistration
Case 2:13-cv-00193
310731027
Document 737-5 Filed in TXSD on 11/17/14 Page 8 of 83
Declaraci6n Jurada de Votante Provisional/ Bim Chtmg Th~ Cua Cu Tri T~m Thai I ~~ili~J:U*:C
TO BE COl\IPLET£0 BY VOTER: Jam a registered voterofthis political subdiv ision and in the precinct in which I'm nllcmptinK to vote nnd have not aln:ody voted in this dcction (either in person or by moi l). I om a resident of
this political subdivision, have not been finally convicted of a felony or if a felon, I have completed all of my punishment including any term of incarceration, parole, supervision, period of probation, or I h:~vc been pardoned. I have
not been dctcnnincd by a final judgment of o court exercising probate ju risdiction to be totally mentally incapacitated or panially mentillly incapacitated without the right to vote. I understand that giving false information under onth
is o misdemeanor. ond I understand that it is a felony of the 2nd degree to vote in an election for which I know Jam not eligible.
(P..\.RA QUE EL VOTANTE LO LLENE: Estoy inscrito como votontc en csta subdiv isiOn politica yen el prccinto en cua l cstoy intcntnndo a voto.r y oun no he votado en esto clccci6n (en persona o por com::o). Soy residcnte de
est a Sllbdi\'isiOn pol it icil , no he sido dclinitivamcntc dcclarado culpable de un de lito grave o si soy e l autor de un deli to grave , he cumplido toda mi condcna inclus ive cl pcriodo de encarcclamicnto , Ia libenad condicional, Ia Iibert ad
supc rYisoda. Ia libertad vigiladn, o he sido indldtado, No me han dctcrminado por un juicio fiMI de una cor1c.dc Ia lcgalizaci6n de un testamento, scr totalmentc incapacitado mcntalmcntc o parcialmcntc incupacitado sin cl dcrecho de
vota r. E_!ltiendo que dar informaciOn falsa bajo juramenta es un dclito menor y tambiCn entiendo que cs un de lito gmvc de 2do grado vota r en una cl~ceiOn sa hiendn que no cu"'!plo con los requisites neccsarios.),(D~·oc HOAN TAT
B(JJ CU' TRI: T6i lei clr tri c:hl ghi dunh bO phit:u ti)i phan khu chinh tri dja phuang n:i y v:'l trong philn khu mil t6i cOy t!inh bO phi~u vll chlm b6 phi eu trong .cuQc b6u clr n:'ly (kC en dich than b6 phitu hoy bO phiC:u bting thu). T6i cu
ngv t\li ph.:in khu chinh trj dja phuong mly, t6i honn to3n khUng bj k~t trong tQi ho~c nCu 13 nguOi ph~m trQng tQi, t6i dii ho:ln th:lnh hCt m9i hinh ph~t. baa g6m thbi h~n tU, :in trco, qu:in cht. thCri ky thlr th:ich, ho~c dil duqc tha. P~:'ln
quyCt cuOi cllng cUa t6a an kh6n~ tuyCn bO rAng t6i la nguOi m~t hofm to:ln nflng hrc v~ m~t tfim thfrn'hay m5t mQt ph.ln nang lvc dC tDi c6 quy~n duqc b6 phi~u. TOi hi~u r~ng khai man khi tuyCn th¢ sC bj ph;;~m khinh t~ji, va t6i hiCu
r.\ng nlu b6 phiiu trong m9t cu9c bju cir m3 toi bi~l 13 minh khong h9i du dilu ki~n.loi sc bj coi 13 ph~m trong •6i dp d9 2.) El3il!~lJUl *-"l!!ilti&ii;t/illlir'JZg;;t;il!~. *-"1illi!llli!l.~*llttt:):ili!!l<Pil!:Wl' (mE!~tll'ill'
1!>.\Wl • 'i'.A10ilti&i5t1i~Z@~ · !:EM~Jlll1if!flg]lifiiifii®~~lE!Jl! • ~eni:Hl1131~!D:ml · !I!~Ii1if!!1~1 · §f<'i\liiJ\\ · fi!lll! · 'lii~ · ~RIJ!!oJEll!1't'fe$li'ZE'.iCilllt~ • *-"t't*lliill'l<Jil~ol!:tili!Qi~'bllEIZlfl'll~'fe~~llilfjj~
!ktthiliil!\\ll!Jil!M • *-"".!lll!1i:litft:~fJFT'®lRk.fl!!W · ~TWfi£9Jl9i!JEic'ff.fg~!ilrt:J1f.Jiii."Fllilll!l'l'll!JWJ!.I.::-.!.Um •
First Name (Nombre) (Ten) (;j!,)
Last Name (Apellido) (Ho) (II£)
(Ten cu) (1\jlfi;j!,)
Middle Name (if i1nv) (Segundo nombre (sl tiene)
en d~m (neu c6J <I'Fa9;j!, ( :5'/l)
Residence Ad ress: Street Address and Apartment Number, City, State, and ZIP. If none, describe where you live (Do not include PO Box, Rura l Rt. or business address) (Oomlcilio: calle y nUmero de apartamento, Ciuda , Estado, y
C6digo Postal: A falta de estes datos, describa Ia localidad de su residencia. (No incluya el apartado de correos, camino rural, ni direcci6n comerciaL)) (Dia chi cll trlr: Ten dU'bng va sO PhOng, Thcinh Ph6, Tieu Bang,
Bltu Oien.
va Ma
& I('
Neu khong c6, xin di~n ta nai quy vi w ngv (Khong dvQ'c de dja chi H9p Thv, Oia Chi ovang Lang ho~c Oja Chi ThU'CYng M~il) !!H±l~tJl:
Jaifl1ifffi,,£G!!i · ~BJ!I·i-3~;j!, f11!il\ilM!11~lll: ) ~
Cj"'ll
Mailing Address: City, State, and ZIP. If mall cannot be delivered to your residence address. (Oirecci6n postal:
Ciudad, Estado y C6digo Postal, sino es posible entrega rle correspondencia en su domicilio). (Oja Chi Glti ThU':
Thilnh PhO, Tieu Bang, va Ma Buu Dien. Neu kh6ng the chuyen thv t&i dja chi cu ngl,l cUa qui{ vi.) !fi!SWffr)il: : ffi ·
IHf1liJ!flil!irn;'l,~ • j!(]ffi[IJI'<i'!!\\it:itiili.'a:B'-Jibr£t~JU: •
:
iJj;j!,Jttlll:f1l0!i!~R ·
Gender: (Optional) (Sexo (Optat ive)) Gi6'i tinh:{KhOng
b~t buoc 11~•J: ( DJlJ!gll'ftJ{)
Male D
(Hombre)(Nam)(!il)
Check appropriate box: Mnrquc el
cuadro apropiado: D:inh dau vfm 6
•hich h\lP :ffil!i-&rnlilf'llli•Ji.l :
TX Driver's license No. or Personaii.O. No, (Issued by TX DPS) NUmero de
su licenda de conducir de Texas ode su Cfdula de ld entidad expedida por
el Departamento de Seguridad Publica de Texas). 56 B~ng U3i Xe cUa tieu
bang Texas ho3c s6 10 c;i nh3n (do BQ An loAn Lao OQng tieu bang Texas
ill · ~fi'Mil'i~tlll!~ • j!(]ali)!'(if · f.111~!li!:!I•.Rii511ltt!l'i ( m'lo/.JI!l!lill
nacim iento: mes, dla, aiio)(NgAy th<ing n3m sanh:
Th;ng, Ngav. Namllli!tBW! : .Fl · B ·if:
Female~
(Mujor)( Nfr)(:iZ;)
Social Security No. (last 4 digits requ ired if you do not have a driver's license or I: D. number) NUmero de
Segura Socia l. (Si no tiene licencia de conducir ni identificaci6n personal, se requiere los Ultimos 4 nUmeros de
su seguro socia l) 56 An Sinh ><a HOi (4 s6 cu6i cUa sO An Sinh xa HQi c3n phAi c6 neu quy vj khOng c6 s6 b~ng
lai xe ho~c 10 ca nhin)
i±el'ti.'~~6!!j ( j!(]Jl!fil;iSi.'ll:tll~fii!\'[email protected]!:tfJ1lil!~6!!l • ID'JtJH!\H'ti.'-FliHt
so
ARE YOU A UNITED
STATES CITIZEN?
(iSOY CIUOADANO/A DE LOS
ESTADOS UNIOOS?) (QUY VJ
C6 PHAI LA C6NG DAN HOA
KY KH6NG?) !~JJb't~Glli~~U!!;?
0
No
(No)(Khong)(i§)
.. .
.
D
Segura Social.) ( Toi chlfa he dllqc cap bang lai xe cua Texas/so
ID ca nhan h o~c so An Sinh Xa H(>i.) 'fJUff~· TX ~'/l!\t1';l;~jdtli)lj/
il!ll.k!i}()j~lfl1li)ljJiXf±~'lt'~ltl1li)lJ
•
..
..
.
.. .
....
.-
X
TO BE COMPlETED BY THE ElECTION JUDGE
Date of Elect ion Fecho de Ia flecci6n
Ngay Bau c.:r ill Ill B WI
.
Per
Hom~
PCT
o:;J..~'-1-i?o
NUm. de Precinto-lugar de votaci6n/Ph3n l<hu noi di sau CU' 50/il!~!t
i l--6 ---(3
')}!.!l!:~l~:!\5
I
Precinct No. where registered
I
CERT/VUID
- ., .:(}_:. _.,. . ,.~:- ,.L(- :- -,- -:-: :
PCT
NUm . de Precinto-inscrito para votar/Ph.3n Khu nai da ghl danh sO/lli~
!Iii~. ~sm!l'i
Type of Election Tipo de Elecci6n
Hlnh Thtic Bau c.:r ill!ill!li~
FOR STATUS:
Authority Conducting Election Autoridod Administrando Ia Elecci6n
Ca Quon Th6m Quyen Tien Himh Bau Cli 3:./ifif!Mt:f/Pf
BALLOT CODE:
voter's s.ign ature area. The Provisional Ballot Stub is generated from the JBC.)
Voter presented acceptable farm of identification within 6 days of
1.
election day.
VOTER PRESENTED ACCEPTABlE FORM OF IDENTIFICATION
0 YES
arNO
Z.
3.
4. _ _
1. - . 0 a iled to present acceptable form of identification or voter
5.
.7
2.
3.
4.
6.
election.
5.
7.
8.
a
lnfnrrnntinn nn fila inrlirntinn nnnlirnnt rnrnn lotorl n
Ill""!
tor ronic.'trntinn
·
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1111111111111111111111111111111111111111111111111111111
310738011
Declaraci6n Jurada de Votante Provisional I Bim Chling TM Cua Cu Tri T~m Thai I Wc~iiH~J~Ji~~
TO BE COMPLETED BY VOTER: I am a registered voter of th is politica l subd ivision and in the precinct in which I' m a n empling to vo te and have not a lre>Jdy votc:tl in th is electio n (either in person o r by mai l). I nm :1 resident of
this politica l subd ivi.c; ion, have: not been finally convtcted of a felo ny or i f a felon, I have comple ted all of my puni shment including any te rm ofinca rcennio n, parol e, supervision, period of probation , or I have hee n pardo ned. I h.Jve
not been determined by 3 final judgment of n court exercising probate jurisdiction to be tot ally menta ll y in c<~pac it a t cd or partially mentally incnpac it atcd without the right to vo te. I underst and that giv ing fa lse information under oath
is a misde meanor, and I understand that it is a fe lony of the 2nd degree to vo te in an el ect ion for which I know I am not eligible.
(PARA QUE EL VOTANTE LO LLENE: Estoy inscrito co mo votant e en esta subdiv isiO n polh ica ye n el precinto en eua l cstoy intentando a vota.r y aun no he vo tado en esto clecciOn (en persona o por correo). Soy rcsidentc de
es ta su bdivisiOn politica. no he side definit iva ment e dcc\arado culpable de un de li to gra ve o si soy el :J.utor de un del ito grave, he eumplido todn mi conde na inclusive cl periodo de enearcc lam icnto, Ia lib ertad condicional, Ia libcrtad
supcrv isada , Ia Iibert ad vigilada, o he sido indu It ado. No me han determinado par un juicio final de una corte de Ia lcgalizaciOn de un tc~tamcnto. scr totalmente incapacitado mcnt almcnte o parcial ment e incapac itado sin cl derecho de
vo.ta r. E!lt icndo que dar informaci6n fa lsa bajo juramenta cs un de lito menor y tamhie n enticndo que es un del ito grave de 2do gra~n votar en una cl~cci6n snb icnd~ que no eu~rlo con Ins requisite~ ncccsar ios. )_{o~·vc IIOAN TAT
BOI CU' TRI: T6i l:i eli tri dil ghi danh b6 phit!u t ;;~ i ph<in khu eh inh trj d ja phuong nay vii trong ph3n khu mil t6i c6 ydjnh b6 phiCu v:i ch11a bO phiCu trong cuQc bfi u eli n:ly (kC d dich th:ln b6 ph it:u hoy b6 phiCu b.1ng thu). T6i cu
ngv tl} i phii n khu chinh trj dje~ phu{.ffig nay, t6i ho:Jn to.im kh6ng bj k~t m;mg tOi ho~c.: n~u hi nguUi ph~m trong t(li, t6i da hoim th:Jn h h~t mQi hinh ph~t. be~o g6m thOi h~n tU, iln trco, quim ch~. thU"i k.Y thlr thckh. ho~c da duvc tha. Phlin
quy~ t cubi cUng cUa tOa in kh6ng tuyCn bb ding t6i Iii ngl!Oi m5t hO<in toil.n nllng h,rc v~ m~ttDm th5n hay mAt rnQt ph~n nf•ng II,IC dt t6 i c6 quy~n duc;rc b6 phif u. T6i hi~u r~ng khai man khi tuyCn the st'! bj ph;;tm khinh tQi, vii. t6i hit?u
rftng niu b6 phi~u trong mQI cu9c b6 u cu rna toi biit 16 minh kh6ng hQi du diiu ki(n, toi sc bi co i 16 ph~m trqng tQi cAp dQ 2.) Ellill !:<':lJ{)(;!: :lf;:;\.loiltif.l(){5f.llll;f'l:L~itill!:<':, ~•,A.'i'f'@:tllil'l~*tl:ilt'Xill!fl<f'll!l'li (f!l§~[<f,1if
tl!l'lil • :lfi:,A.loilti&il5~ 1ll;:LJiii!:<': · l!E*~m1fffi>lllli'iii>J&l~£;nl • ~~flll!\l!l8fiili>ll · !§ffi1fr&1i'J · i;Jt5~1i!i · W~ · f.i'g · i.l1ifUl!oJE.I:fi:\'!:7'M!!~E1&j\j(~ • <$:;\.l!E*II>il:l'li!l{®ll!itilib'iWHi~lt~fi11$i'i;~~8B{j)~
9<iiEt.Jili'i!!\IHHii!W • :lf;:;\.8Jl lt'f:Oi'fiH!i:~iJFF1'H'!~RlofJ!~Il · ;ttTI!'itE8)j):{]l3cT-ff~~~rt:J1ll/i51.rtl:ill$<f'llll'illo=t&!liml •
last Name (Apeilido) (HQ) (tl)
First Name (Nombre) (Ten) (;lS)
Midd le Name (If any) (Segundo nombre (si tiene)
en dem (neu c6) •NMS ( '61f l
Former Name {Nombre anterior)
(Ten cu) (1\i Ill:&!
Resi ence Address: Street Address and Apartment umber, City, State, a nd ZIP. If none, describe w ere you live (Do not include PO Box, ral Rt. or busin s add ss) {Dom iciiJo: calle y nUmero de apartJmento, Ciudad, Estado, y
C6digo Postal: A falta de estes datos , describa Ia localidad de su rcsidencia. (No incluya el apartado de correos, camino rural, ni direcci6n comercial.)) (Dia chi ell trU : Ten dl!Ctng
sO PhOng, Thanh Ph6, Tlfu Bang, va Ma Bvu Oien.
Neu khong c6, xin di~n
ta nai quy vj w
va
ngv (Kh6ng dllc;rc de dja chi HQp Thll, Dia Chi Dllbng Lang ho~c Oia Ch i Thllang M<i) I JEf±l~lll:
jlj:l',l~l.il:'!iJi::liiil~
:
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Ma 1lin g Address:
"f ma il cannot be del ive red to your residence address.
Ciudad, Estado y C6d igo Postal, si no es posible entregarle correspondencia en su dom icilio).
Th3nh Ph6, Tieu Bang, v3 Ma Bllu Oi~n. NC'u kh6ng the chuyen thu t6i d ja chl cLt ngv cUa quyvj.)
tli'!ilillr.i!!l~~
nacimiento: mes, dfa , ai'io)(Ngcly thang n~m sa nh :
Thong, Ng!y, N'ml
ill~ B lVI
: !'l · B · if.
• iln!!:!ml~!i\>:iti15i:t !J; (!';JJEjlft!li]J: •
Male,t:Y"' Female 0
(Hombrc)( Nam)(!/l)
cuadro apropiado: f);:lnh d5u v:Jo 0
thich hqp tl:illl'lit1Jl1\i*J(]J1/1;):
TX Driver's License No. or Personal I. D. No. (Issued by TX DPS) NUme ro de
su licenda de conducir de Texas ode su Cedula de ldentidad expedida por ·
el Departamento de Seguridad Publica de Te xas) . 56 B3ng Lai Xe cUa th!u
:
(Mujcr)(NU)(:!;c)
Social Security No. (last 4 digits required If you do not have a driver's license or 1.0. number) NUmero de
Segura Social. (Sino tiene licenda de conducir nl identifrcaci6n personal, se requiere los Uhimos 4 nUmeros de
su seguro socia l) SO An Sinh xa HOi (4 sO cu6i cUa sO An Sinh xa HQi dn ph;li c6 n€u quy vj khOng c6 sO b~ng
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ARE YOU A UNITED
STATES CITIZEN?
(i SOY CIU DADANO/A DE LOS
ESTADOS UNIDOS?) (QUY VI
C6~AI
KY K
(
LA CONG DAN HOA
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( Co)(:ffi;)
0
(No)(Kh6ng)(i§)
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Home Per
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PCT
County Clerk Usr ONLY
02.
NUm. de Prednto-lug<lr de votaci6n/Phan Khu nO'i da B"au Clt S6/U!w;~
II- 0 s-:J.ot3
• •
•
TO BE COMPLETED BY THE ElECTION JUDGE
Date of Election Fecho de lo Elecci6 n
Ngly Bau Cil il!li! 8 l\ll
. •
l have not been issued a TX driver's license/
Number. !No me han expedido una licencia de conducir de
Segura Social.)! T6i ch11a he dt!qc cap b~ng lai xe cua Texas/so
ID ca nhan ho~ c so An Sinh Xa H<)i.) ftiSl_'l'f TX 'f!i'Z~~¥M.<Htl16l'j/
0
CERT/VUID
PCT
6087
Precinct No. where registered -:-:-:--:::-:-:-c--::-=.
NUm. de Prec into·in sc rito para vota r/ Ph:in Khu nO'i dii ghi danh sO/}RLTI;
!lii~.
H"1nh Thl1c Bau Cil ii!!ll:m!l:i
:M:EcJt!lrli
FOR STATUS:
c
,n 1 ~I (;L,J.?C-77(.:1. -
BALLOT CODE:
13._ 3 !1 § _jJ
-
the following conclusion(s) was mode:
X 2-
{Write in the Ballot Code, it is found on the Provisional Ballot Stub above the
FOR VOTERS WHO DID NOT PRESENT ACCEPTABLE PHOTO /DENT/FICA T/ON
1.
election day.
0 YES
1./
~NO
2.
3.
4. ~/Voter executed natural disaster affidavit within 6 days of election day.
Failed to present acceptable form of identification or voter
certificate with exemption .
5.
_£
2. Vvoter not on list.of registered voters.
3. / v o t e r not on list, registered in another precinct.
4.
5.
FOR VOTERS WHO VOTED PROVJS/ONALL Y FOR OTHER REASONS
6.
election.
7.
Voting after 7:00 P.M. due to court order.
8.
Q
lnfnrmntinn nn filo inrlirntinn nnnfirnnt rnmnlotorl
n
untor ronic-trntinn
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310920554
Declaraci6n Jurada de Votante Provisional I B<'m Chtmg Th~ Cua Ctr Tri T?m Thai I im~~B;;~M"TO BE COMPLETED BY VOTER : I am a registered voter of this poli tical subdiv ision and in the precinct in wh ich I'm allempting to vote and have not alreDdy voted in this electio n (either in person o r by mai l). I am a resident
this political subdiv ision, have not been finally convicted ofu felony or ifo felon, I have complctcc.loll of my punishment including any term -of incarceration, paro le, superv ision, period of probation, or l have been pardoned. I hu vc
not bee n determined by a linal judgment of a court exerc ising probate jurisdiction to be totally mentall y incapacitated or partially mentally incapacitatctl without the right to voh:. I undcrslilnd that giving fa be informat ion undt:r oath
is a misdemeanor, and I understand rhat it is a felony of the 2nd degree to vote in an elect ion for which I know I am not eligible .
(PARA QUE EL VOTANTE LO L..LENE: Estoy inscrito como votnnte en esta sutx:livisi6 n politica yen cl precinto en cual estoy intcntnndo o votnr y oun no he vo tado en cst:J clccc i6n (en persona o por corrco). Soy rcsidcntc de
esta sutx:livisi6n pol iti co, no he sido dcfi niti vamcnte declarado culpable de un de lito gra ve o si soy el au tor de un dcli to grave, he cump lido tod:l mi condcna inclusive cl pcriodo de cncarcc lamicn to, Ia Iibert ad condiciona l, Ia Iibert ad
su pcrvisada. Ia li bc rtad vigi lada, o he sido induhado. No me han dctcrminado por un juieio finn I de una corte de Ia lcgalizaciOn de un testamento, se r totalmcntc incapacitado mcnltllmcntc o parcialmcntc incapu ci wdo sin cl dcrccho tk
vo!ar. E_!lticndo que dar informaciO n fab:a bajo juramenta cs un de lito me nor y tambiCn cnlicndo que es un de lito grave de 2do grado votur en una el~cci6 n sobicndo que no cun~plo con los requisite~ ncccsa rios. ). (Ul/QC HOAN TA'r
801 CU' TRJ: TOi l;l clr tri d;1 ghi danh bO phicu t;;ti ph:in khu chinh trj dja phuang nay v;ltrong ph:in khu mit tOi e6 Ydinh bO phi6u vi:l chua bO phiCu trong cuQc b5u cU n:i.y (kC c:i dk h th:in bO phiCu hay b6 phiCu b:lng thu). T6 i cu
ng~ .t;;ti p~iin khu chinh trj djo phucrng mly, t~i hoi\n tofm kh6ng. bj k~ttn~ng tQi ho~c n~u l;i nguc'Ji P,h1,un trQn~ tQ i, t6i ~a ho oi n th:inh.htt mQ i hi~h ph~t , bao gbm thOi h;;t~ tU •. 3n lrco, qu:in cht. thOi k)' thU th3ch, ho~~ da duqc tha: r.~:in
quyCt cu6i cUng cUa t6a :in kh6 ng tuyC:n b6 ri'lng t6i 1:':1 nguOi milt ho:in toi:m nang lvc ve m~t t:lm thi n hay miit mOt phiin nang h,rc d2 t6 i c6 quyC n du~;n: b6 phifu. TUi hiCu r;ing khai man khi tu yC n th~ sC bj ph~m khmh t\>i. v;J tOt h11!u
r~ng n~u b6 phiiu trong m6< cuiic bfiu eli rna <oi bit <Ia minh khong ho i du diiu ki¢n, 16i sc bi coi Ia ph~m trong <oi dp do 2.) E!Jill~lJiR ;t;:.A.~ilti(!{ iat',JHl:iF'!Z~itill~ . ;!;:,/dij''tt.!I!!J3.(1,1*{£11t=xilllll<Pllt\Vi <mi3~H'ili.'f
tl!.!illl • ;t;:.A.~iltil'J ial?lrn;zg~ · tt*tlilm#m:~iffil!'.di!M:rE!m · ~~nr..e'l! .m~m;m · !E!Pfi:t.~mtm · E!l1itiJ;t; · ~1 RI · ~tr · Wlf!Jl!oJEtlt¥Z>VI!-OIGElfi~~ • ;t;:.ld:t*lfiiU<Wa~;a;tliJQi~'mlttnffll~>t~~ffi;M~
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• ;!;:),.AJJ!JiUil!flrt!G;fJ\1-'Cf'i'i~R.'M'1111 · :Jf!H~{£nJlt.IJEJcHr~'i'itllif.Jlmi5Lrt£illlfl9'tl1~~=ttlili!Jll·
Name (Nombre ante rior)
Name (if any) (Segundo nombre (si tlene)
last Name
dem fneu c6)
'I'Pn9;g ('i5'1'f J
cO)
(ftlfll;g)
s
Residence Address: Street Address and Apartment Number, City, Sta te, and ZIP. If none, describe where yo u live (Do not include PO Box, Ru ra l Rt . or bu siness address) (Domicilio: calle y mimero de apartamento, Ciudad,
C6digo Posta l: A falt a de estos datos, describa Ia loca lidad de su residencia. (No incluya el apartado de correo s, camino rural, ni direcci6n comercial.)) (Oia chi Cll trU: Ten dllb'ng v~ sO PhOng, Th<lnh Ph6, Tifu Bang,
Mii Bvu Dien.
Niu khOng c6, xln di~n Ia nai quy vi cU' ngv (Kh6ng dU'~c de dja chi Hop ThV', Oia Chi OV'cYng lang ho~c Dja Chi ThU'ong M~i)) Ji!if.l)/tltl : !ij:1';Ji!!fi!:W01it~,~ · nT • tl·/:fUIJil;llfli]a¥ • 91J!Io;Ji# ' 1l'i:'f!llllJIIJilJi!i!f.l/t!li ( fu1o/JiflillB
va
FolliHii'i!\'!!!l · ~illlH3 !.'<:!jfji)J;t[lli~Jtli!!ltU
nacimiento: mes, dfa , ai'\o){NgAy thang nam sanh:
Th ang, Ngav. Nam) ill !E. 81~ : !'J · 8 · 1J:
Female 0
Male
(Ho mbre)(Nam)('IJ)
Check appropriate bo;.;: Marque el
cuall ro apropiado: D:inh d~u vflo 6
<hich hOJ1 1'£iPl'llt1Jtsr"ll.'l•J-tJ :
Q_J;_Q~IJq&l
(Mujcr)( Nii)(:!x:)
Social Security No. (last 4 digits required if yo u do not have a driver's license or t.D. nu mber) NUmero de
Segura Socia l. (Sino tiene licencia de conducir ni identifica ci6n perso na l, se requ ie re los Ullimos 4 nUmeros de
c6 s6
su seguro social) sO An Sinh Xii HQI (4 s6 cu6i cUa sO An Sin h xa HQi dn phal c6 nEu quy vj
lai xe ho~c
10 ca nhan)
lift~~'l!!!!!l (
so
ARE YOU A UNITED
STATES CITIZEN?
HomePCT
Date of Electio n Fecho de Ia Efeccicin
Ngav eau c!r il!l!lB Wl
'i!\'. IJ11",<Jit!li
CERT/VUID
0 L T cJF
Voter Registrar Us e ONLY
PCT
11
NUm . de Prec i nto~inscrito para votar/Ph::m Khu nal da ghi danh s6/iH~
!Q'l!!. !l:ecli!!!li
Type of Election Tipo de flee ciOn
Hl nh Thitc B5u Cir ~l!ll;liili
PCT
OV35
NUm. de Precinto-lugar de votacl6n/Phan Khu nai dil B'au c& S6/illm~
FOR STATUS:
Authority Conducting Election Autoridad Administrando Ia Elecci6n
Ccr Qvan Tham Qvyi!n Tien Himh Bav Cv 1:/ifif!i'!Jt!lliV
I, the voter registrar/deputy registror, did research the records of my office and
the following conc/usion(s) was made:
BALLOT CODE:
l l q .2_ t..f g.!._ z._
~
1.
election day.
DYES
~NO
2.
3.
4. -
1.
Failed to present acceptable form of identification or voter .
2.
3.
4.
5.
Voting after 7:00P .M. due to court order.
/Voter executed natural disaster affidavit within 6 days of election day.
5. ~
6.
election.
7.
8,
9.
Information on file indicating applicant completed o voter registration
1111111111111111111111111111111111111111111111111111111
310830036
.,·
Declaracion Jurada de Votante Provisional I Ban Chung Th~ CL!a Ctr Tri T;;nn Thai I !m~iR~~~~
TO HE CO.\IPI.ETEU HY VOTER: I :1111 ~ rq~is ta~.·J mter oft hi.'. rulit il·:JI ~uhl111"i~in11 anJ in dw rrl'rinct in \\'hid1 I'm illlcmpling to Volll' and have not :llrciJJy roted in 1his clcctmn (ci lhcr in pcrsnn or hy muil ). I ;~m u rl.'sidcm of
thi:'\ polili,:al ~l1hJi , i.-i(•n. h;J\l' 1101 been lin:lll~ l'•HI\'it:ll:d o f <.J fduny or if a felon. I h:.~vc compkll'll ;~IJ ,,r my pu11is lum:nt 'im:luc.Jing any term of inGm.:crution. parok, supcr\'iSilln. pcrioU ofprob:J\iun. or I have hc~.·n pardoned. I han:
lhll ht'l'll dt'll'rlllincJ by:) rmal juJgJl\t'l\1 uf:ll'll lln c.x~.·r~i~in~: prob:J\1.' jurisdlclion (0 b.: hl t:'l lly mcnt:dl~ im:;.~pacilalt:d or Pani.:.J II y m..:ntally incap.:~cii:Hcd without the right 10 \'OIC. r unckr~tamJ thai giving lUis~ inli.lrmatiun UtHh:r oath
is :1 misJcnw:mur. :m d I unlit·rsl:..l!lli th:u il is a IChJny llf lltc: 2nd tJ..:gn:c 10 \'Ut~ in an ch:~o:tinn lOr which 11-:nuw I am no\ eligibk .
No Original Affidcivit :.... ·ceo nlade copy ,'
(1'.-\H :\ ()Ul [I. \ 'UTA;\T[ LO LLE.\'£: E.siOY ir
inh·t.}tando iJ \'~tar y aun ~10 he ~·otado Cl~ t.'~l:.t clccci6n(cn r .c rsun:.t 0 ~or cu rrco). ~~y r. .•sidt·~t..: de
...·s1~ subdi1·isiOn pv litira. 1111 he sidt' J..:linitivumcnl(· .
umphlio toda tm c0ndcnn mclu SI\'1.: d pcnodo de cncarccl:.umcnto, Ia hhcn od conJtctonaL Ia hbcrtad
supcn·j,.;;JJ:t. Ia libcnad Yig il:tJ:1. o h..: :.ic.lo induh ado.
un tcswm.:nto . scr tot.almcm . .· incapaciltH.lo mcn lah ncn lc u pan:ialmcnlc incupaci1aJo sin cl d. .·rcdm tk
\utat L~Ht~.:nJo qu ...• J.1r mlllrm.t~.:lon 1.1ba b.tJU ,IUnllll
lo Vt l\a r ctt u1w ekc:c:iOn sabicndtl 4uc no cump lo t.:o n los n.:qui:.it . .)S nt.:~o7csarios.) (OU'(jC UC),\;'1\ T,\T
80 1 ( Ll 1 HI TOI ],1 (U tn d.i ~ Ill J:JI\h ho pliiC U t.l ll
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ng\• .t;,Ji pl.\~ II khu~o:hinh l rj <.lja phUITll£ ni•Y: t~i hn;ln 10~10 klnl ng.bi kti LrQng 1\'l i hu~c 1\~U JU nguOi p_hl.l111 tn,m~ ,,'li. tl>i ~[i hoitn thilnh _h~t nwi hit~h pht;ll , bao g6t~lth0i h:.ll ~ nJ .. Un Ireo. '4u;iu ch.C . th~i k)' thlr t~uich, ho~l: t.IJ d~I\Jl: tha: r.~;in
L.J.UY~I ~·t1 t"11 cimgyUutOa .ln khimg tu.yC n btl r:'mg ttii l;i ngubi m:it hoiln to:ln n~ng lvc vC m;;tt t:lm th;jn hay m:it m(u ph;jn n~ng lvc dC tOi cO ljU)'i:n duqc bO phiCu . TOi hi..!u r:lng khai man l.: h1 tu yc n th~ s~ b1 ph:.tm kh1n h 11)1, v:i tlH lucu
rang u~ u b\1 phi~u tro ng m\ll ('tL(Ic b:·su rlr milti1i bi~t lil minh kh0ng h¢i dU di~u k i¢n. tO i s~ bj cui li• ph:.tm tn,:mg t~'li dp dQ 2.) r±lill~Jj'.('f.;~ : -.f.: A b\lltif.l;EfM!M'LZ ~i;[j,E[\(. ~~ J, 1~·:\JNii.firi~Hk<±.lH:~}\lli.H&r~f!l~ (ffl(J!&!61;f!f
l'lWiJ • ~: l,l)~t fU;fSI&2foll\' · I>£:HW~-Iif ifiY~ifiil!'i@ t'iJE!l11 · ~r,gpf~ ail!f!i.tJUn · i!:!Jli'!~i!;iiil · @1~'0.\'#i · l 'H:f · tii·N' · ~llf!Jl~J E'. Il!~'J\:!II!<Ii e1tt.I'<!X: • ;!;)..r,~;!: i!>i~'iill<;i::l!;t;~J£~<;H.I:li:f!.Wil~ 1 'ii::·"~liffi:JH~
:1cliEJJfflili\l!Qi'liim • :.f'/.'~liiJl.E:lit'tt:!Jii!'o:]'t'tVilREl11'Uo · 1I'Tfi!i'£J:'lilll!Eic:Ff.F€s~ I30'JtnnLt!lHll<f'I'J.l\'i1~::-.tJ.UWJl! •
Last ~mJ
(Apellido)(Hol (tt;
(T cO)( tj nJ :i:,)
Middle Name (If any) (Segundo nombre (si tiene)
en d~m [neu c61
~VLD(I ;J
~'li:li',
( 1!i'iif I
Residence Address: Street Address and Apartment Number, City, State, and ZIP . If none, describe where yo u live (Do not include PO Box, Rural Rt. or business address) (Domicilio: ca11e y nUmero de apartamento, Ciudad , Estado, y
C6digo Postal : A fait a de estos datos, dcsc r iba Ia localidad de su residencla . (No incluya el apartado de correos, camino rural, ni di recci6n comerclal.)) (O ja chi ell trU : Ten dvb'ng va sO PhOng, Thanh PhO, Tieu Bang, va Mii Bl.fu Dien.
Neu khiing co. xin dien ta
Jf,j(ig!1i~H!!!i·'iP'':
nai quy vi w ngv (Khiing d11o-c de dia chi H¢p Thu, Dia Chi D11~ng L<\ng ho~c Dia Chi Th11ang Moil I @{£Jt!:lJI: : lfii>l!Ehl:'lti:'C:!i>li~ · iii · HH"li!W>l:fl.(l;l)}t • JalMko!ff;l. • ~,)O!fW!511RJJ/iiH:Elt!::!il ( M~llm!&J;
.,, ••. \~.J(I;u
V'YloS~~
Mailing Address : City, State, and ZIP. If ma il ca nnot be delivered to your res id ence address. (Oirecci6n postal:
Ciudad, Esta~o y COdigo Post al, si no es posiblc entregarle correspond encia en su domicilio). (Dja Chi GLri Thv:
Thinh Ph6, neu Bang, va Ma Bllu Dien. Neu khOng thf chuyen thv t&i dja chi cu ngu cUa quy vj.) '!f!~t'flttJll: : ?fj •
Gender: (Op!ionaii(Sexo (Optative)) Giai tinh:(Khiing
b~' buoc tmJ: ( nJIXH:ItFJJ'O
'"ii?'·?Lr'Tfu ss~
Check appropriate box: Man.JUC cl
,,:u a<.lro apmpiadtJ : DUnh d&u v;io 6
1hich h(<p
ft~'iii'11tiii'-Jm'l i:J
:
Male 0
[HombreJIN:tmi(Vl l
TX Driver's license No. or Personai i.D. No. (Issued by r.x DPS) NUmero de
su lice ncia de conducir de Texas a de su cedula de ldentidad expedida por
el Departamento de Seguridad Publica de Texas). SO sang Lci i Xe cUa tieu
Date of Birth: Month, Da y, Year (Fecha de
na 'm iento : mes, dia , ai\o)(Ngay thci ng nam sanh:
ang, Ngay, N>ml LI:\~Elllll : F! · E1 • lf
Female
(Mujcr)( Niil("!l:J
Social Security No. (last 4 digits required If you do not have a driver's license or I. D. number) NUmero de
Seguro Social. (Sino tiene licencia de conducir ni iden t ifi caci6n personal, se requiere los Ultimos 4 nUmeros de
su seguro social) 56 An Sinh xa HOi (4 s6 cu6i cUa s6 An Sinh xa HOi c'an phili c6 nfu qu'( vi kh6ng c6 sO bang
~
•
•
'
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•
L!
ARE YOU A UNITED
STATES CITIZEN'I
!;.SOY CIUDADANOIA DE LOS
ESTADOS UN OS'!I (QL!)' VI
CO
PHA I LA
<)NG ,DAN
IIOA
KY KHONG''
D
(SiJ< Col( ill)
•
-..
No
(NoJIKhiingl(i!il
•
.•
. •..•.
-
•••.•
l
J
I
Texas/CedUia de identidad personal de Texas ni un NUmero de
Seguro Social.) I T6i chlta he
dii!)'C
cap bang lai xe cua Texas/so
ID ca nhan hoijc s6 An Sinh Xa H(>i.) 'fJUJ.'fii TX ~!l'iM!I¥.ilt.£ 1i)!j/
f!OIJ....flrfli'f.lt\J,~Ii'!llfZU~'tt:"f:~Rfil!i •
X
Home PCT
PCT
Date or Elect io n Fec ha de Ia Eleccidn
Ngay Blu Ctl ill:!ll E1 UIJ
~~v5(2.D!f
NUm. de Precinta-lugar de vataci6n/Phiin
9,1.
li':~fll!:ll\\
CfRT/VUID
PCT
NUm . de Prec into-inscrit a para votar/P hiin Khu noi da ghi danh
s6/.ifi~
ill'l.~. :;,~ficll!:!!l';
Type of Election Tipa de Elecci6n
Authority Conducting Election Autoridod Administranda Ia ElecciOn
Hinh Thirc Bau C~:Jill'l
c~a"~mHsBouCvC~~-
..:r~rn1
FOR STATUS:
the following conclusion(s) wos made:
BALLOT CODE:
voter's signature area . The Provisional Ballot Stub is generated from the JBC.)
1.
election day.
VOTER PRESENTED ACCEPTABI E E_QRM OF IDENTIFICATION
---=:::
- ~0
DYES
~0
Vater met disability exemption within 6 days of election day.
1..
4. _ _
1.
5.
£
2.
3.
4.
5.
6.
election.
7.
Voting after 7:00P.M. due to court order .
8.
Registered to vote in o different precinct within the county.
...
....
•.
1111111111111111111111111111111111111111111111111111111
310846537
Declaraci6n Jurada de Votante Provisional I Bim Cht'mg Th¢ Cua Cu Tri T~m Thai I lfti~i.R~~~:e
TO BE COMPLETED BY VOTER: I am a registered voter of this pol it iced subdivision and in the precinct in which I'm aUt:mpting to vote and have not aln:ady
i
person or by mail). I am a resident of
this politi..:u l subdivision, have nut been fina ll y convicted of a felony or if a felon, I have completed all of my punishment induJinc any tenn of incarceration, pa role, supervision, pcri01.l of probation, or 1 have been pardoned. I have
not been determined by n final judgment of a court exercising probate jurisdiction to be totally mentally incapacitated or partially mentally incapacitated without the right to VOl C. I understand that giving false informatio n under oath
(PARA QUE EL VOTANTE LO LLENE: Es10y inscrito como vat ante en est a subdivisi6n politica yen el precinto en cua l estoy intcntando a votary aun no he votado en esta elccc i6n (en persona o par corrco). Soy rcsidente de
csta subdivisi6n politica. no he sido dcfinitivamcmc declamdo cu lpable de un del ito grave o si soy cl autor de un de lito grave , he cump lido toda mi condena inclusive el periodo de cncarcelamicnto, Ia libertad condicional.la libcrtad
supcrvisadu, Ia libcnaJ vigi lad a. o he sido indultado. No me han dctcrminndo por un juicio linal de una corte de Ia lcgali:nJci6n de un testamento, .sc r totulmcntc inc:Jpacitado mcntalmcnte o parciulmcnte incaraeitndo sin cl dcrcc.:ho de
vo:a r. E.ntiendo que dar informac i6n fa lsa bnjo jummcnto cs un de lito menor y tambiCn cntiendo que cs un de lito grave de 2do grn~o volar en una c_l~cciOn sabicnd~ que no cun~plo con los rcquisito~ nccesarios._) (Dl_J'<)C IIOAN TAT
801 ClJ TRI: TOi l:i clr tri dol ghi danh b6 phiCu t~i ph5n khu chinh tri din phtrang nily v:i. trong ph<in khu rna tOi c6 y djnh b6 phiCu v3 chua 00 phu:':u trong cuQe b:iu eli oily (kC d. dlch th5n b6 phiCu hay b6 ph1tu Mng thv). T6i cu
ngl,lt;;~i ph:in khu chinh tri dja phuang n:iy. t6i hoftn to:in kh6ng bj k~t trong tQi ho~c n~u l:i nguOi ph:,un trong tQi. t6i dil ho<in th:\nh h~t moi hinh ph;11. baa g6m thOi h~n tU, <in trco , quin cht, !hOi k)' thlr thich. ho~c da dvqc tha. Ph:in
quy~t cuf>i cUng cl1a tOa ;ln kh6ng tu yCn b6 r~ng t6i hi ngLrOi mfit ho3n toim nfmg h,tc v~ m~tt3m thin hay m3t m¢1 phJn nang h,Jc d6 t6i c6 quy~n dltQC b6 ph1~u . T6i hi~u dng kh:1i man khi tuyCn th¢ s~ bj ph~m khinh tQL vii t6i hi~u
r~ng n~u b6 phi~u trong mQt cuQc bfiu clr m£1 t6i bittl:i minh kh6ng hQi dU di~u ki¢ n.t61 s~ bj coi l:l ph;_~m trQng tQi dp dQ 2.) EW.s!BUA~: "$A ~!ltif~1)5f~ ~JAJL..g.;~iii~. *Af-fJ!! OO.Il(~*:(fitt.:XillH?lrf:lia}W (~l:l~\Z["'~
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last
first Name
i
Name (Nombre anterior)
I Name
dom fneu c6)
<PrJI~
( 'iii=i'f)
cu)
(\(1ffi~)
Gwstrt
Residence Address: Street Address and Apartme nt Number, City, State, and ZIP . If none, describe where you live {Do not include PO Box, Rura l Rt. or
address) (Domicilio: calle y nUmero de apartamento, Ciudad, Estado, y
C6diga Postal: A falta de estes datos, describa Ia localidad de su resldencla . (No incluya el apartado de correos, camino rural, ni dlrecci6n comercial.)) (Dia chi cu trU: Ten dlllYng va sO Phbng, Th3nh Phd, Tifu Bang, va M3 Bllu Olen.
Neu kh6ng c6, xin dlen ta nai quy vi w ngv (Kh6ng
~vac ~e dja chi
&\\n.:\
Hop Thv, Oja Chi OlfiYng Lang hoac Oja Chi Thlfang M<i))/i!l{l;Jt!'.J:il:
Foif1H1i'lllbl!l· :<!19f~~~~~~:;xi!li\111l~l:il:J
Mailing Address: City, State, and ZIP. If mail cannot be
to your
address . (Direcci6n postal:
Ciudad, Estado y C6digo Postal, si no es posible entregarle correspondencia en su domici lio). (Oja Chi Glti Th ll:
Thanh Phd, Tifu Bang, va M3 Bu'u Dien. NCu kh6ng thf chuyen thll tCti dja chi cll ngv c~a quy vj.) !!61!fjfuJt : ffj ·
l·lifll!!tii'lf~;JR
:
ll'i,gJJtllf:f!JZ}1.il~
(Hombre)(Nam)(!/l)
ARE
• jl[)JQ;JH'i. • lllM'"Wi:li.BJl@{1lltl!li ( ffi'Jo/JI!l!mi
nacimiento: mes, dia , aiio)(Ngay thoing n3m sanh:
Thang, Ngay,
MaleD
TX Driver's license No. or Persona I I.D. No. (Issued by TX DPS) NUmero de
su licencia de conducir de Texas 0 de su Cedula de ldentidad expedida por
el Departamento de Seguridad Publica de Texas). SO B3ng l ~i Xe cUa tieu
bang Texas ho~c sO ID ca nhan (do 86 An To3n Lao OQng th~u bang Texas
iiif!J!IIJ:tllli~
Gender: (Optional) (Sexo (Optative)) Gi6'i tinh:(l<h6ng
bit buoc fig'): ( OJlj'{~T-lJi)
• W:ll!:!!li'"*li\Utitffi!a:A"-JF.Sf't.lt!'.l:il: •
Check approprirnc box: Marque el
cundro apropiado; E>flnh ddu v:io 0
thich hO'P "(fjl!i11t:IJt:lr'lilJIJ1:J:
· iii ·
Female~
Nom) :±l~ 8 Wl : Fl • 8 · lf'
(Mujcr)( No)(~)
Socia l Security No. {las t 4 digits requ ire d if you do not have a driver's lice nse or 1.0. number) NUmero de
Segura Social. (Sino tiene licenda de conducir ni identificaci6n personal, se requiere los Ultimos 4 nUmeros de
su seguro social) sO An Sinh xa HOt (4 sO cu6i cUa sO An Sinh xa HOi dn phai cO neu quy vi kh6ng c6 sO b3ng
lai xe ho~c s6 10 cil
YOU
STATES CITIZEN?
(LSOY CIUDADANO/A DE LOS
ESTADOS UNIDOS'!) (QUY Y)
KY KHONG?) !~Jl!.!f<lil<l:L\f\';'!!;?
~es
0
No
(Si)( C6)(Jl!:)
Per
NUm . de Precinto-Jugar de votaci6n/Phan Khu nal da B~u Clt SO/UIJ;gtei
:m.!ll~lt!'.l'i
_2__(_5_____
Per
NUm. de Precinto-inscrito para votar/Phan Khu nai da ghi danh s6;rn;m;
Type of Election Tipo
Hinh Thfrc Bau Clt
illll!:tW111
FOR STATUS:
Authority Conducting
Autoridad Administrando Ia Elecci6n
ca Quan Th6m au yen Tien Hanh Bou cv I/ififUfft'l/;1!
He-rr 1~
Co'.V\-f
BALLOT CODE:
l
Q.Q 0_ (£6 7 ] ~
voter's signature area. The Provisiona l Ballot Stub is generated from the JBC.)
1.
election day.
0 YES
1.
_:f_
!d NO
2.
3.
4.
5.
cancelled mail ballot application .
2.
3.
4.
S.
d
6.
Not a registered voter or registra~ion not effective in time for this
election.
7.
8.
9.
Information on file indicatin!J applicant completed a voter reaistration
lllflflllllllllllllllllllllllllllllllllllllllllllllllll
310847518
Affidavit ofProvisionalVoter
Declaraci6n Jurada de Votante Provisional I B<'m Chl!ng Th~ Cua Cu Tri T~m Thai I !i~~~J~Ji~fi
TO BE COMPLETED BY VOTER: I am a registered voter of this political subdivision and in the precinct in which I'm nllcmpting to vote and have not already voted in this election (either in person or by mail). I am n residen t of
this political su bdi vis ion, h:l ve not been finally co nvi cted of n ldony or if n felon. I have comp leted Dll of my punishment including any term of incarceration, parole, supervis ion; period of proha tion, or I have been pard oned. I have
not been determined by a final judgment of a co urt exercising proba te jurisd ict ion to he totally mentally incapacitated or partia ll y mentally incapacitated without t~c rieht to vote. I undcrswnd.th:lt l!ivine false information under oath
is ll misdemeanor, and I understand that it is a fe lony of the 2nd degree to vote in an elec tion for which I know I am not eligible.
(PARA QUE EL VOTANTE LO LLENE: Esioy inscrito como VOIDnJe en csta subdivis i6n politica yen el precimo en cual esiOy intcntando a VOlar y :JUO no h
csta subdivisiOn politica, no he sido definitivamcmc dcclamdo cu lpab le de un de lito grave o si soyclau tor de un dclito grave, he cump lido toda mi co nd cna in clt
supcrvis ada, Ia Iibert ad vigi lada, o he sido induhado. No me han dctcrminado ror un juicio final de una corte de Ia ICJ:;alizaciOn de un testamento, scr towlmemc 1
votur. E .~tic ndo que dar inforiTIJci6n falsa bajo jurnmcnto ~:sun d~.: litu mcnor y tambien entiendo que cs un del ito grave de 2do gra9o vota ren um.l cl~cci6n sabie1
B(H CU TRI: TOi Ia ell tri d3 ghi dan h bO phil:u 1\li ph3 n lchu chinh tri djn phlrong mly va !rang ph5n khu m<i t6 i c6 'f d jnh b6 phieu va cht.ta bO phiCu trong cuQc
ngl,ll;;li philn khu chinh trj dju phuang nay. tOi hoi:m toiln kh6ng bj k~l tn,mg tc~i ho~c n~u [;l nguOi ph;;.m lfQng t¢i, tOi da hoim th;inh hEt mQi hinh phyt, baa g6m ti
quy~t cu6i cUng cUa tOn :in kh6 ng tuyCn b6 r~ng t6i l;i ngt.tOi mit hmln to;in n:lng lvc v~ ~ttiim th:i n hay m8t mQt phfin ncing h,1c d~ t6i c6 quyi:n duqc b6 phi~ u .'
r~ng nl:u bO phiiu trong mQt cuQc b5u ell mil t6i bi~t IDminh khOng hQi dU di~u ki~n. tO i sC bj coi l;i ph;;.m trc;mg tQi dp dQ 2.) Et!U!e\:11{!~: *A~~i&;&t,Ha;l
l!liWI • 'I'.A~Jlti&)f.if.!H.Il:Z/l!itii; · ~t*ltl18*i"illmlilfi*t&!A'JEml · !i1W/lf/!1lli8'i'l!f!'ll1 · @f'/T1'J!!.\g;J · §t<'i\!ii~ · 11:H~ · \!ii'l;l' ·
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provisional
MOORE MARlA ELEN A
2195 WIN ROCK BL VO
HOUSTON, TX
77057
DOB : 11/17/1963
1
BS: 56-N-P
t!ilfl f.;JE'.IJ!:'Itlt-l! !it
Last Name (Apellido) (Ho) (!If)
First Name (Nombre)
(Ten) (~)
Middle Name {if any) {Seg undo nombre {s i tiene)
en d~m (neu co) 9'Po9~ (:iii*!)
(Te ncu) ((;!fll~)
Residence Address: Street Address and Apartment Number, City, State, and ZIP. If none, describe where you live (Do not include PO Box, Rural Rt. or business address) (Domicilio: calle y nUme ro de apartamento, Ciudad, Estado, y
C6digo Postal: A fal ta de estos datos, describa Ia localidad de su residencia. (No incluya el apartado de correos, camino rura l, ni direcdOn comercial.)) (Oja chi ell trU: Ten dub'ng va sO PhOng, Thanh Ph6, lieu Bang, va Ma Bllu oien.
Neu khong co, xin di~n ta noi quy vi w ngv (Khong duqc d1! dia chi Hi)p Th11, Ilia Chi !lu~ng Lang ho~c Ilia Chi Thuong M~i)) Ji5j±lfu!J!: : 1!j~I~IJHD01i!~R · nJ · jiolf-0~/l~!lli~,£ • !4H!l)Ji'lif • lii'iiffii!I~I!IJ@ {j)~!M ( 'in"W/ll~l
1
PJ LJd .
z~cf5'~m!itc;jl~) 0 reO
~
Malllng Address: City, State, and ZIP. If mail cannot be delivered to your re sidence addre ss. (Direcci6n postal:
Ciudad, Estado y C6digo Posta l, si no es posible entregarle correspondenc ia en su domicil io). (Oja Chi Gtii ThU':
Thanh PhO, Tieu Bang, va Mil Blfu £lien. Ne'u khOng thE! chuyen thu t&i dja chi ell ngv cUa quy vj.) !fill*tt3Jll: : ffi ·
i!fftlllF>l§liJ;It'i· !ID!.I!~F>llf!l\i,l:Jlilil!r:A~@f±J~I:Jl: •
~~7_
{J~~¢ptu(JY
[00\
Check appropriutc box: Mnrque cl
cuadro apropiado: E)flnh d~u vao 6
1hich hqp :(fji!i•fit15tiiJ"JilJ1/1:) :
Date of Birth: Month, Day, Year {Fecha de
nacimiento: mes, dia, aiio)(Ngay thang nim sanh:
Thang, Ngly, Nlm) i:l]~ 13 ltll : fl · 13 • J]'
TX Driver's license No . or Persona II.D. No. (Issued by TX CPS) NUrnero de
su licencia de conducir de Texas ode su Cedula de ldentidad exped ida por
el Departamento de Seguridad Publica de Texas). SO B3ng L<ii Xe cUa t it?u
:
Male 0
(Hombre)(Nam)(J/l)
Female
~
j_ 1_ I j_ ~I _j_
9 (Q_3_
(Mujer)(Nil)(:i1;)
Seguro Social. (Sino tiene licenda de conducir ni identificaci6n personal, se requiere los Ultimos 4 nUmeros de
su seguro social) 56 An Sinh Xii HQi (4 sO cu6i cUa sO An Sinh X3 HQi dn phai cO neu quy vi kh6ng c6 sO b3ng
•
.
'.}
•
i!i
~
~
ARE YOU A UNITED
STATES CITIZEN?
(;.SO Y CIUDAD ANO/A DE LOS
ESTADOS UN IDOS ?) (QUY VJ
HOA
c6 PH AI LA C. G DAN
D
(Si)(Co)(~)
N0
(No)(Khong)('i§)
•
0
•
Date of Election Fecha de Ia Elecci6n
Ngly Bliu Cv illf!l Elll/l
11
lsl13
e
•
• .
••
()
j
HomePCT
J..1
•
I
'
I •
I
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!'.
IJI,~. tltl\'i~!!\5
CERT/VUID
(J
I ~~
:ll:ocJIEIM
=
Honh
PCT
DIJ-
FOR STATUS:
Autho rity Conducting Election Autoridad Administrando Ia Eleccidn
ca.Q"~~ ;~~
012
?7ft:;oO; 3o
NUm . de Precinto·lnscrlto para votar/Ph3n Khu nal da ghl d nh so/ll!mi
!~::fft.
PCT
S D IMO
NUm. de Precinto-lugar de votaci6n/Ph3n Khu nai da eau Clt S6/~~tlii
Precinct No. whe re registered
Type of Election Tipa de Eleccicin
Hlnh Thu-c B~u Cv il!!fllill!l:i
I
personal ident ification number or Social Security
Segura SociaL) ( Toi chU'a he dU'qc cap bang lai xe cua Texas/so
10 ca nhan ho~c so An Sinh Xa H¢i.) ft59.~ TX ~ll'l:VJ\~9f!li1Jli
I~.A.!HBm ~Rli!!l~U w'ti'U'tli!!l·
rt:::~N
BALLOTCODE:
1
~2t5.5_16j_
voter's signature area. The Provisional Ballot Stub is generated from the JB C.}
l.
election day.
0 YES
1.
kl'1Jo
VFailed to present acceptable form of iden tification or voter
2.
3.
4.
5.
Voting after 7:00P.M . due to court order.
2.
Vater met disability exemption within 6 days of election day.
3.
4.
S.
JL'"
6.
Nat a registered voter or registration not effective in time for this
election.
7,
8.
q
lnfnrmntinn nn filp inrlirntinn nnnlirnnt rnmniPtarl n 11ntPr ronictrntinn
-
- - - - - -- - --
lllllllllllllll/111111111111111111111111111111111111111
310847536
Declaracion Jurada de Votante Provisional I Ban Chtmg Th~ Cua Cu Tri T~m Thai llm~ill~J~~~
TO BE C0!\'1PLETED BY VOTER: I am a registered voter of this political subdivision and in the precinc t in which I'm ancmpting to vote and ha ve not atrca~" ............ :- .~.:_ -•- ···
thi.s po litical subdi vision, have not been fin all y co nvicted of a fe lo ny or if a fe lon. I have completed llll of my pu nishment including any term of incarceration,
not been dctcm1incd by a lina l judgment of a coun exerc ising probate jurisdiction to be tot oily mentally incopilCiHllcd or puni<:~ ll y menta lly incapacita ted witho
is a misdemeanor, and I understand that it is a felony of the 2nd degree to vote in an election for which I know I am not elig ible.
1
'f
Provisional
CROWFORD, VELORIA
1918 ROSEWOOD ST
HOUSTON, TX 77004
008 11/14/1926
BS 19-N-P
(PARA QUE EL VOTANTE LO LLENE: Estoy inscrito como volanle en c.sla subd ivisiOn polilica ye n cl prccinto en cual csloy in lcnland o a vo lar y aun no
csla subd ivisiOn polilica, no he s ido dclini ti vamcntc dcclarado cu lpable de un dclilo grave o si soy el a utor de un de lit o grave. he cump lido toda mi condena in;
supervisada, b lihcrtad vig il ada. o he sido indullado. No me han determinado po r un juicio linal de una con e de Ia lega lizaci6n de un testamento , sc r totahncnt
vo lar. Enlicndo que dar informaci6n fn lsa bajo jurnmcnto cs un de lito mcnor y tambien emiendo que es un del ito grave de 2do grado vot:lr en una e lecciOn sabi
BOt clr" TRI: TO i l:l clr tri dil gh i danh b6 phiCu t{li ph:ln khu chin h tri dj:J phucmg n;ly vil trong ph:in khu m;ltOi c6 y d jnh b6 ph it u va chua bO phitu trong CUo
ng v 1~i ph5n khu chinh 1rj dja phtwng nay, tOi hoim to;ln kh6ng b! k~t trong tQi ho~c n~u l:i nguOi ph:,lm tron9 tQi, t6i d3 ho:i.n lh;lnh htt mQi hinh ph(lt, bao g6m
quyEt cu6 i cUng cUa t6a 3n kh6 ng tuyCn b6 rfing tOi l:i ng utJi mit ho;ln to5. n n!l.ng lvc v~ m~t t:lm thin hay m:it mQt phfin nang lt,rc d~ t6i cO quy~n dlrqc b6 ph i~1:..
c
r
. .. . _ __ - · .- . -- · -· .......
rftng n€u b6 phi~u lmng m(it <uiic b~u ctl mi t6i bi~ t 1; minh khong hiii du diiu ki¢n. toi sc bi coi Ja pb¥m "ong tiii dp dii 2.) Ebill!.'I:IJ'll'.!: :;t;:).1!1Jtti&il5fiiiill!i'!Zgit:Ul!.'l:, -:4>:A'I~:t!~ll.fol*iEitt'):Ull!l'l'lll:Wl <WEI~!If>llf
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Last Name fApellido) fHo) (ld;)
Fi"t Name (Nombre) (Ten) (~)
Middle Name {lf any) (Segu ndo nombre (si riene)
en dem (neu co)
former N01me (Nombre anterior)
( :i!i'R)
'l'lb~~
(Te n cii)(\'llRJ~)
or£
Residence Address: St et Address and Apa rtme nt Number, City, State, and ZIP. If none, describe whe re you live (Do not include PO Box, Rural Rt. or business address) (Oomicilio: ca lle y nUmero de apartamento, Ci ud ad, Estado, y
C6digo Postal: A fa lta de estos datos, describa Ia localidad de su re sidencia . {No incluya el apa rtado de correos, camino rural, ni di recci6n comerciat.)) (Oia chi cU' trU : Ten dU'bng va sO PhOng, Thanh Ph6, lieu Bang, va Ma Bllu men.
Neu khong c6, xin di~n ta nai quy vi cU' ngv (Khong dU'Q'c de d)a ch; Hop ThU', Dia Chi ovang Lang ho~c Oja Chi Thvang M•il) @illl!li.JJ: : 1.fii'.ll!:t!l:f1l07Jl;'l!l · ill · ltlf1l~~'ilHR;~R • j!!)Jni'>!*! • il'Wl't-lll~ltRJll§ f111!:1!\l ( ffilo/Jifl!ill
wtJecf.
1
mtl3r>i'lJlQ!Ij·Jll~f~M~~~ &Jili~[)
8
lx
~sft.JrL
Malting Address: City, State, and ZIP. If mJil ca nnot be delivered to you r residen e address. (Direcci6n posta l:
Ciudad , Estado y COdigo Postal, si no es po sible entregarle correspondencia en su domicit io). (Oja Chi GLti ThU' :
Thanh Ph6, TH~u Bang, va Ma Buu Dien . Neu kh6ng the chuyt!n thu t6i dja chi cu ngv cUa qu'{ vj. ) !J!tH~f!ltlll: : iji ·
lf'?DO
Gender : (Optio nal) (Se xo (Optative)) Gi&i tinh:(KhOng
Thang, Ngly, Nam)
iHRI!If>i!lilll!ll!i • j!O!l!o!lf>'ili'!!llii!:ili~!.T:If:Jii5f1Jilih[ •
Male O
th lch hQp {£@1l\1Jllll*liJ11J1;) :
TX Driver's license No. or Personal I. D. No. (Issued by TX DPS) NUmero de
su licencia de conducir de Te xas ode su CE:dula de ldentida d expedida por
e l Departamento de Seguridad Publica de Texas) . 50 sang Liii Xe cUa tieu
W~B
Wl : }'l · 8 · fJ'.
Femal~
(Hombre )(Nam)(!Jl)
Check arprop ri::~tc ho x: Marque cl
cuadro apro piado : f)6.nh diu v3o 6
Date of Birth: Month, Day, Yea r (Fecha de
nacimiento: mes, dia , aflo)(Ngily thilng n ~ m sa nh :
bat bui)c f18t): ( nJIJ(~;rJ):()
(Mujer)( Nii)(:!!;)
Social Security No. (last 4 d igits requ ired if you do not have a driver's license or l.D. number) NU me ro de
Segura Social. (Sino tiene licencia de conducir ni identificaciOn persona l, se requiere los Ultimos 4 nUmeros de
su seguro socia l) SO An Sinh Xii HQi (4 sO cuOi cUa sO An Sinh Xii HQi can phil i c6 n€u quo( vj kh6ng cO sO bo\ng
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ARE YOU A UNITED
STATES CITIZEN?
(;.SOY CIUDAOANO/A DE LOS
EST ADOS UNIDOS?) (QUY VI
KY KHONG?) !.T: :i£9'<1ili10£\:'!~?
Aves
0
(Si)( C6)(Q)
No
(No)(Khong)(i!l)
:
0
•
I
•
I
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Texas/Cedula de identidad personal de Texas n; un Numero de
Segura Social.) ( Toi chua he dll\)'c cap b~ng lai xe cua Texas/so
ID ca nhan ho ~c so An Sinh Xa Hoi.) tti.\l.:fil TX ~~~!1.\lliR!i!lli
@},!l/Billl!R!i!ll~t±l!f'?t'~ldtli!ll·
Date of Election Fecho de fa Elecci6n
Ngly Bau c.:r Ull!lB WJ
Hom ePCT
0JO
Prec inct No. where voted
PIT
PIT
SRJ> I MO
NUm. de Pre clnto-lugar de votaci6n/Phii n Khu nai 11.5 Bau Clr S6/llH!HJi
')Jl. llt\Wii!l~,\
CERT/VUID
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0710
NUm . de Pre cinto*inscrito para votar/Phiin Khu nai dii ghi danh s6/iB ~
!=H!IJt.
Type of Election npo de E/ecci6n
Hinh Thvc Bau c.:r ill!lll'lill:i
~:C.II!ll!\l
FOR STATUS:
Authority Conducting Election Autoridad Adminisrrando fa Elecci6n
ca Quan Thom Quycn nen Htlnh Bou cu _
1jifJifi:liiJIPf
1-\Q~.---,s
C..ou~-l
BALLOT CODE: ~~~S fJ_ t 3
+_
voter's signature area. The Provisional Ballot Stub is generated from the JBC. )
1.
Voter presented acceptable form of identification within 6 da ys of
election day.
1.
_L
D YES
::rz(No
certificate with exempt ion .
z.
3.
4.
5.7
2.
Vote r not on list of registered voters.
3.
4.
5.
6.
election.
7.
Voting afte r 7:00P.M. due to court order.
8.
9.
Inform ation on fiiP. indicntinn nnnlir:nnt rnmniPtPrl n vntPr rPni<;trntinn
Registered to vote, erroneously fis ted in wrong precinct.
310850013
Declaraci6n Jurada de Votante Provisional I Ban Ch{rng TM Cua Cu Tri T~m Thai I !m~il!~JU\si!
TO BE COMPLETED BY VOTER: I am a reg is tered voter of this pol itical subd ivision and in the prec inct in which I'm attempting to vote and have not already vo ted in th is elect ion (either in person o r by ma il). I am a resident of
this political subdivisio n, have not hccn fin:~lly convicted of a IC:Iony or i f a felon, I have comp leted all of my pun ishmen t including any term of incarcerat ion. parole, supervisio n, period of probatio n, or I have been pa rdoned. I have
not been determined by a fi na l judgment o f a court exe rcisi ng probate jurisdictio n to he totally mentally incapacitated or partia lly mentally incapucitatcd without the right to vote. I understand that giving false informatio n under oat h
is a misdemeanor, and I understand that it is a felon y of the 2nd degree to vote in an election for which I know I <~m not eligible.
(PARA QUE EL YOTANTE LO LLENE: Es10y inscrito como vownte en esta sutx:l ivisi6n politica yen e l precinto en cual estoy intentando a vo tar y au n no he vo tado en es ta clccc i6n (en persona o par correo). Soy res idente de
csta subJ ivisi6n polilica, no he siUu dclinitivamcnte tleclaradu culpable de un de lito grave o si soy c1 <Jutor de un dclito b'TilVC, he cumplido toda mi cundcna inclusive c\ periotlo de enca rcc lamicnto, lil libcrtad comliciomd, Ia lib crt ad
supcrv isadu, Ia libcrtar.l vig ililda, o he sido indultado. No me han dcterminado pur llll juic io final de una corte tic Ia lcgali%ilC i6n de untcstilmento . scr towlnn.:ntc illl:upacitado mcntalm~..::ntc o parcialmentc inca pacitado sin cl dcrccho de
volar. Emiendo que dar informaciOn falsa bajo juramenta cs un del it o me nor y tambiCn enticn<.lo que cs un de lito grave de 2do b'TDdo volar en una elccciOn Silbicndo que no cumplo con los req uisite s nccc~arios.) (DU'Q'C HOAN TAT
BOt elf TRI: T6i hi clr tri d3 gh i danh b6 phiCu l<,l i phiin khu chinh tr j dja phuang na y vii \rang phUn khu mil t6i c6 y djnh bO phi~u vii chllil bO phitu trong cuQc b&u cU nDy (k~ d dich than bO phi~u hay bO ph i~u bang tllll). TOi Cll
ngv .tQi p~<in khu chinh trj dja phuang nay! t~i hofl n toDn khOng. bj k~t tn:;mg tQi ho~c n~u hi nguOi r.hQm tron~ tQi, tOi ~i.i hoUn thimh. h ~t mvi hin.h ph;,1t. baa g6'!' thOi h\l~ tU,yin trco, qu:ln ch~ . thO'i k)' thlt thJc h. ho~c d ~ duqc thil. P~~n
quyCt cu6 i cUng cUa tOa :in kh6ng tu yC n b6 rang tOi 13 ngLrOi mdt hoim to:ln nling lvc vC m~t tdm than ha y mat mc,)t phii n n:ing lvc dC t6i c6 qu ye n duqc bO phi Cu. TOi hit!u rang khai miln khi tu yC n th~ s~ bj ph:;tm khinh tQ i, v:i t6i hiCu
ring niu b6 ph;iu trong m\it cu(lc b~u cir m:i 16; b;itJj m;nh kh6ng h6; du d;iu k;in. 16; sc bi co; lil ph1m trQng 19; dp dQ 2.) Ellill~lJ(!l!: O!'A.~ltti&iCif~llliF'lZ~ii'<ill~. :.l>:A.1'iil<'lili.l3.Ml*1fltt'P.:illlflrplll:!/# (~Elli'ZID~llf
ll!3Ml • *A.1Mti&i6fli~Zii1iti! · ltt*li<ll81ii'ID~ffiill!i@i~IE~ · !XDJlfiei'JI18=/'i!lilJil · {E!pfi=lf!!\i'J · @.lt\lHii · W.ll'11 · 'fu\''§' · i!1Jfii~Bilt~5tWliltBll!iil'<~ • ~'J..r;t*ll!ii1l!!lliiiil!itfi!lt1~~lft)tiLJflllqt;;t ftli'Z8WHQ;
9<:fle:!Jililliillll:Jillli • 'I'A.flE!IIl!:m:£'1Jtl!l:IJii'Ft'!~oR~G~ · i!E71!'¥1f"JlillE!B'FFF~'il!M''lt~ili'.T1filllii<PI!h'/i~.=.!iHIH11 •
lost Nome (Apellido) (HQ) (i(E)
First Name (Nombre) (Ten) (;f:1 )
Middle Name (if any) {Segundo nombre {si tiene)
en di;m (neu co) 'i'ra9:t ( :Jii=i'i)
(Ten cO) (Wfll:t)
Residence Address: Street Address and Apartment Number, City, State, and ZIP. If none, describe where you live (Do not include PO Box, Rural Rt . or business address) (Oomicilio: calle y nUmero de apartamenlo, Ciudad, Estado, y
C6digo Postal: A fa It a de estos datos, describa Ia localidad de su residencla. (No incluya e l apartado de correos, camino rural, ni direcd6n comercia l. )) (Dia chi cv trU: Ten dLtCng va sO PhOng, Thilnh Ph6, rieu Bang, vii Ma Bllu Oien.
Neu kh6ng c6, x;n dien ta nai quy vi cv ngv (Kh6ng d\JQ'C d€ di• chi Hi)p Th\1, Oi• Chi Ol1bng lang hojc Di• Chi Th\Jang M•il! ~llltill:tl: : lfi~lti!IJ!:'f!l01!<\lfl , ill · itl'f!l[ljl'*llBJl • JtO!l!ilJ.:j;j' • ID'IaHII!ii!lflEII§(lVJ!l'l'; ( 51lo/Jifl!['(l
JBJmli'i\lflJi!ll · ~9 f~!.'.l16 filliiltilli!f!Utl!l:tl: J
ll6
residence address.
Ciudad, Eslado y C6digo Postal. si no es posible entre garle correspondenc.ia en su domicilio) .
Thanh Phc5, Tieu Bang, va M3 BLtu Oien. Ne'u kh6nc th e chuyen thv t&i dja chi cv ngv cUa quy vj.)
Gender: {O pt iona l) (Sexo (Optativo)) Gi&i tinh:(KhOng
bat buiic t<£~1J : ( OJII.(J;Ii,'f lll J
TMng, Ngav, Nam) :±l~B Wl : Fl · 8 · if.
JiiWffil!ii'i!Jl;>fli • !tllM!ffili'ilt!ii\ii'<iiiii!if:8'JJ§i1Jtlll:tl: •
thich hqp tEiN'il\J.i!i'IF*liD'Jt:J :
ARE
YOU
A
UNITED
STATES CITIZEN?
(;.SOY CIUDADANOIA DE LO S
ESTADOS UNIDOS?) (QVY VI
C6 PHAI LA CONG DAN HOA
KY KH6NG ?) fm~:Je~i~.!:\:11,1~?
afv"es
(S;)(C6){~)
D
No
)No)(Kh6ng)(jli')
TX Driver's license No . or Personal I. D. No. (Issued by l)( DPS) NUmero de
su licencia de conducir de Texas ode su Cf dula de ldentidad expedida par
e: l Departamento de Seg urid ad Publica de Texas). 56 sang L3i Xe cUa t ieu
bang Texas ho~c sO 10 ca nhan (do BO An Toan lao DQng t ieu bang Texas
.
persona l identification number or Socia l Security
Texas/Cedu la de identidad personal de Te xas n; un Numero de
Segura Social.) ( Toi chua he dt!Q'C cap bang lai xe cua Texas/so
ID ca nhan ho~c so An Sinh Xa Hoi.)'f.Ji;)~11J TX 'm~t\'A~\l51Jt!!Jll
•
(Mujcr)(
Nii)(:i()
Socia l Security No. past 4 d igits required if you do not have a d river's license or 1.0. number) NUmero de
Segura Social. (Sino tiene licencia de conducir ni identificaci6n personal, se requiere los Ultimos 4 nUmeros de
su seg uro social) s6 An Sinh X3 HQi (4 s6 cu6i cUa s6 An Sinh X3 HQi dm phai c6 ne'u quy vi khOng c6 s6 b~ng
l!i xe hojc so ID ca nhanJ U~'?i~!ll!i!'J ( Jt(JW,!/U)ll.=i'i!i'lil'l:tll!!«li'Z®A.~IHO!!!II!!I!l • rul!Ji!IJ\U:It-FQlJi:
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Date of Election Fecha de Ia Efecci6n
Ngav Bau c& il!li!B Wl
lQ_; _Q_~; 1 ~n_
Male~ Female 0
(Hombre)(Nam)(!/3)
Check npproprintc box: Marque cl
cui.ldro apropiildo : Dilnh dfiu vilo 6
Date of Birth: Month, Day, Year (Feche~ de
nacimiento: mes, dia, ai\o)(Ngay th3ng nam sanh:
Home PCT
NUm. de Precinto-lugar de votaci6n/Ph5n Kh u nai dii B'au Clt S6/in~W
SW12AV
'll!!. lll:i\liltil!!.l
CERrNUID
PCT
DS42..-t
Vote r Rrglstror Use ONLY
PCT
O
r,/~
Precinct No. where registered -""'-'-',;,;'--'"t----...,...,NUm. de Precinto-inscrito para votar/Phii n Khu ncri da ghi danh s6/Dl~
!lii>fli:Ji!Wtl!/!11
Type of Election Tipo de Eleccidn
Authority Conducting Elect ion Autoridod Administrondo fa ElecciOn
Hlnh Thl!c Bau C!r ill!flUill:i
Ccr Quan Tham Quyen Tien Honh Biiu Cv 3;/ifjJJI$/tflilf
FOR STATUS:
0'u1'N'i-
r"'-~ /!!}. ~of-{ 'f7
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BALLOT CODE:
(Write In the Ballot Code, it is found on the Provisional Ballot Stub above the
voter's signature area. The Provisional Ballot Stub is generated from the JBC}
1.
election day.
.D YES
L
ifNo
Failed to present acceptable form of identi fication or voter
certificate with exemption ,
z.
3.
4.~ Voter executed natural disaster affidavit within 6 days of election day.
5.~
2. __
t-\/oter not on list of registered voters.
3. ..._.----Voter not on list, registerethrranother-precinct.
4.
5.
6. /
election.
7.
Registered to vote, erroneously listed in wrong precinct
8,
Registered to vote in o differPnt precinct within the county.
9.
Information on file indicotina aoolicant comoleted a voter rPaistrnrinn
M£
11111111111111111111111111 11111111111111111111111111111
310862509
Declaraci6n Jurada de Votante Provisional I Ban Ch{rng Th~ Cua Cu Tri T?m Thai I li!F.fill~~~i!
TO BE COl\ I PLETED BY VOTER: I am a registered vo ter of this po litica l subd ivision and in the precinc t in wh ich I'm anempting to vote and have not a !ready voted in this election (e it her in person or by mail). I am n res idem of
thi s political subd i\'ision. have not been finally co nvicted of a felony or if a felon, I have completed all of my punishment including any term of incarceration, parole, supervision, period ofprobatKln, or I ha ve been pardoned. I have
not been dctcnnined by a final judgment of n coun exercising probate jurisd ict ion to be tow!l y mentally incapaci ti.l tc d or part ia ll y mentally incapacitated without the right to vote. I undcrstund th<~l giving falst: informal ion under oath
i5 a misdc:meano r, and I undt:rstantlthat it is a felony of the: 2nd degree to votc: in :m election fur which I know I arn no t eligible.
(PAR.-\ QUE. EL YOTANT£ LO LLENE: Estoy inscrito como vot antc en es to subdiv isiOn politica yen cl preci.nto en cua l estoy intentando a votary aun no he vo tado en csta decc i6n (en pe rsona o par corrco). Soy residcnte de
est a subdi \' isiOn pol itica, no he sido de fin it ivamcntc dccla rado culpable de un de lito grave o si soy c l au tor de un de lito grave, he cump lido toda mi conde no incl usive cl pcriodo de cnca rcclamicmo, Ia Iibert ad condiciona l, Ia li bert:Jd
supcrvisada. l<J libertad vig ilnda. o he sido indultado. No me han determinado par unjuicio lin<~ I de unn corte de Ia legnlizac i6n de un testamento, scr totu lmcnte incapacitado mcntalmcntc o rarcia lmcntc incapoc itoLio sin cl derecho de
voLar. Emiendo que dar informaciOn falsn bajo juramenta cs un de lito mcnor y tambiCn cnt icndo que es un del ito grave tic 2do grado volar en una clecei6n snb iemlo que no cumplo con los requ isi te s ncc csarios.) (DU'QC HOAN TAT
801 C(f TRI: T6i 1.3 cti tri dil ghi danh b6 phieu t:.1i ph5n khu ehinh tr! din plnrang nfly va trong ph:in khu mfl t6i cO)' djnh b& p hi~u va chua b6 ph i~u trong cuQc bfiu eli nay (k6 cit dich than b6 phii:u h:~y bO phi~u b~ng tim). T6i w
ngv Li~i ph5n khu chinh tri diu phuong n:ly. tOi ho:into3n kh6ng b! k~ t tn;mg tQi ho~c n~u 1:1 nguOi ph€1m trqnp tQi. t6i d5 ho:in th;lnh h~t mQi hinh ph:;u, baa g6m tht'Ji h;)n tU, :ln trco, qu:in ch6. tht'Ji k)' thlr th:ich, ho~c da duqc thn. Phin
qu y~t cu6i cUng cUa tOa :in kh6ng luyCn b6 r~ng tOi loi ngu6i m5t ho3.n toim n~ng h,rc: v~ m~t t:im thin hay mat m¢1 phAn nang h,rc d~ tOi c6 quy~n dugc bO phiCu. TOi hi~u r~ng khai man khi tuyCn th¢ sC b j ph:;un khinh t¢i, v:i t6 i hi~u
rang n~u b6 phiiu lrong mot cu(>c blu Clr ma toi biit lj minh kh6ng hoi du diiu ki¢n. toi sc bi co i lj p h~m lrQng t(> i dp do 2.) E!Jili~lfl.'!g: ~-J..~Jttif'.<i~f.li~F'<JZgi;l;il!~. 21<J..1i'Ji!:ll!i.Eli<\i*'f£ltt:J:illlll•Nltilli (fj/EJ~~~*
tltWil • 21<J..1'liH:i£li~Mk1liZJiii~ · tE*l§lE1-lifHllffii1Cililtm£1Jll · ~~n~i\!JE1-l!li;E · lliffi'lll!\ii11 · il!lt'i,Uf; · ll':lll' · ~'Ill' · &!!Jllll';JE'.t:!1~'ii:lJ!.~E'.1Ciil!l!e • 21<A.tE*1Cii!;ltJil~illi~li1@!¥1ltii'.fllfiilqt'fi:~~llfll111'<
9i:ijG;/Jffiil!f.l~Uill!rl
• 2i<.A.Ijlj ffi7.1F£t1JH!ill!'<'f'L'!J:'1jR~f!l!'J11 · Mi.n~'fEHJ!~ElcH'fgpfiifntilli.RT"'f£illrll'l'lll:l\V:;=tJ.lffiill1·
-· ·•. Name(Nombre)(Ten) (:jl,)
Last N·
Provisional
Resid
C6dig
Ne'u
~
(Ten cu) It! l!l:jl,J
Midd le Name (If any) (Segundo nomb re (si tiene )
en dem (neu c6) <1>r.1:g ( :S'Il l
TINDELL, MARCIA BACA
3503 SYCAMORE SHADOWS DR
KINGWOOD, TX 77339
DOB 02/28/1939
BS 11-N-P
tiP. If none, describe where you live (Do not include PO Box, Rural Rt. or business address) (Dom icllio: calle y nUmero de apartamento, Ciudad, Estad o,
v
~o in cluya el apartado de correos, camino rura l, ni direcciOn comerc ial.)) (Oja chi ell trU : Ten dvb'ng va s6 PhOng, Thc'lnh Ph6, lieu Bang, va Mii Bllu Oien.
Oia Chi Ollimg Lang ho~c Oia Chi Thvcrng M9i)) J-:S!±JitlJI:
:
!tj:jl,J;t!J!:fa~lll'M
· m· iilfaffillllHlliM • ~n!l!i§!'ll · :,m:!ffi;j(BJI@!1Jit!\'i ( ii'io/JI!l[rf\
l"lfili
- -
·-
-· - _ )
Mailing Address: City, State, and ZIP. If mail can not be delivered to your residence address . (Direcci6n pos tal:
Ciud ad, Estado y C6digo Postal, sino es posible entregar le corresponden cia en su domicilio). (O ja Chi Glti ThU':
Thanh Ph 6, Tieu Bang, va Mii Bllu Oien. Ne'u kh6ng the ch uyen thll t&i dja chi ell ngy cUa quy vj.) !.im~ltf.!f : iff ·
Gender: {Opt'ional) {Sexo (Opta tive)) Gi6'i tinh:(Kh6ng
b~t bu(ic lt:Jl<J: ( ii)Jjt;Jt'f!JI )
Jmumr.ll!lll];llll • JzD!l! !W~fl!f.itillil!.'i'.:B'J~!±llt~t •
MaleD
(Hombre)(Narn)(!Jl)
Check appropriate box : Marque el
cund ro apropiudo: Elimh diu v:io 0
th ich hqp .{Eiljl!;Jjjj!f'lUJtJt) :
ARE YOU A UNITED
STATES CITIZEN?
(iSOY CIUDADANO/A DE LOS
ESTADOS UN IDOS'I) (QUY VJ
CO PH AI LA CON G DAN HOA
KY KHONG?) .'.2!:llbliHlll0!l1P'!;?
0
(Si)(C6)(:!il:l
No
(No)(Khrlng)(i'i')
TX Driver's Li cense No. or Personali.D. No. (Issued by TX DPS) NUmero de
su licencla de conducir de Texas ode su Cedula de lde ntidad expedid·a par
el Departamento de Seguridad Publica de Texas). 56 B ~ ng L<ii Xe cUa tit!u
bang Texas hoa c sO ID ca nhiln (do BQ An Toan La o OQng tii~u bang Texas
.
nacimiento: mes, dfa, aflo)(Ngc'ly thtlng nam san h:
Thang, Ncav, Na m) tlJ!E El Wl : Fl · El • ~
Female 5J./
I
Number. (No me han expedido una /icencia de conducir de
Segura Social.) I Toi chlla he dllt;tc cap b~ng lai xe cua Texas/so
ID ca nhan ho~c so An Sinh Xii H(>i. ) titi.)t:fif TX 'l'il:~fA!w.!!l!b!li
•
Social Security No. (last 4 digits requ ired if you do not have a driver's license or 1.0. number) NUmero de
Segura SociaL (Sino tlene lice ncla de conducir ni identificaci6n personal, se requiere los Ultimos 4 nUmeros de
su seguro social) SO An Sinh Xii HQi (4 sO 'cuOi cUa sO An Sinh X3 H¢1 can phJi c6 n€u quy vi kh6ng c6 sO b~ng
!ai xe hole so lO ca nhan)
1±e'li'~llll6!!l ( illl*!~i§!'llffl~tM~~II!l.A.~M~'iJ!Ii!'J · ID"lmi!\U'Ii'-r.ruHJt
-
td·+- K.
.-
•'
X
I ___ _
(Mujer)( Nii)(:il:)
.
@A.gfsmt~~~U®"~~!!I!b!J
Date of EJection Fecha de Ia Elecci6n
Ngay Blu Cit illl!l El WJ
Date of Birth : Month, Day, Year (Fecha de
HomePCT
Per
{)6/Z -11
I
NUm. de Precinto-lugar de votaci6n/Phan Kh mtfda B'au Cil SO/Ui~~
M. tllJ':HIM1i
Precinct No. whe re registered
{[)
PCT
GI ';;L.
NUm. de Precinto-inscrito pa ra vota r/Phiin Khu ndi da ghi danh sO/)ii~
!&\iii. '!Hcltl!ru
Type of Election Tlpo de Eleccf6n
Hlnh Th(rc Blu Cll ill!fl~@'/
FOR STATUS:
Authority Conducting Eled ion Aucoridod Adminisrrondo Ia Elecci6n
Ccr Quon Thorn Quyen Tien Himh Bau cr.f ~Nil!NI!lMl
/, the voter registrar/deputy registrar, did research the records of my office and
BALLOT CODE:
119. ~ j
~ .1 ~-
(Write in the Ballot Code, it is found on the Provisional Ballot Stub above tl'le
voter's signature area. The Provisional Ballot Stub is generated from the JBC.I
1.
election day.
0 YES
1.
a?'No
2.
3.
4.
S.
V
2.
3.
4.
6.
Nat a registered voter or registration not effective in time for this
election.
Voter on list of people who voted early by mail, and vot er has not
5.
7.
8.
9.
Information on file indicating applicant completed o voter reQistrotion
lllllllllllllllllllllll
ll llll llllllllllllllllll l lll
310862518
Declaracion Jurada de Votante Provisional I Bfm Chl:mg Th~ Cua Cu Tri Tc;tm Thai I ~!ey}l~~~ii
TO BE COMPLETED BY VOTER: I am a registered voter of this political subdivision and in the preciuct in which I'm attempting to vote and have not alrcad.v ·
this political subdivision. have not been finally convicted of a felony or i f a felon, I have compktcd <~II of my punishment including any term of incarceration, pai
not been determined by a fmal judgment of a court exercis ing prob:ue jurisdiction to be totally mentally incapacitated or parti;:~ l ly mentally incapacitated withou t I
is a misdemeanor, and I understand that it is a felony of the 2nd degree to vote in an t.:lection for which I know I am not eligible.
Provisional
MCNAUGHTON, LU CI LLE ROSE
2310 PINE TERRACE DR
KINGWOOD, TX 77339
DOS 09/05/1933
BS 11-N-P
(PARA QlJF. EL VOTANTE LO LLENE: Estoy inscrito como vot<~ntc en esta subdivisi6n polltica yen cl prccinto en cual cstoy intentondo a votary aun no h;
esta subdi visiOn politica, no he sido dcfin iti vamcntc dcclarado culpable de un del ito gra\;C o si soy cl autoi de un de lito grave. he cumplido toda mi condcna incl u
supcrvisada, Ia li bcrtad vigil ada. o he sid o indultado. No me han dete rm inado por un juicio fina l de una co rt e de Ia lcgaliz.aci6n de un testamen to, ser tota.lmcntc j.
vo.tar. E~ t icndo que dnr informaci6n ft~lsa bajo juramen ta cs un de lito menor y tambiCn cnt iendo que c.~ un delito grave de 2do gra?o vota r en una el~cei6n s:~bicn'
BOI CU TRI: T6i 13 eli tri d:i ghi d::~nh b6 phiCu t::ti phlin khu chinh trj dju plnrang n:iy viltrong ph:in khu mil t6i c6 y djnh b6 phiGu va chua b6 rhif:u trong cu(lc1
ngv t=;~i ph:ln khu chinh tri dja phucrng nity, t6i ho:in to:in kh6ng bi k~t trong tQi ho~c n~u 1;1 nguOi ph=;~m tron~ l ~i. t6 i dl'l ho3n th:lnh h~t moi hinh ph{lt , bao g6m 1~
quy~t cu& i cUn g cUa tOa :in kh6ng tuyCn b6 r~ng t6i Iii nguOi mAt hofm tofm n3ng lvc
m~ t tlim thcin hay mlit mQt ph~n nang lvc d~ t6i c6 quy~n duc;rc b6 phi~u. \.
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rjng n~u b6 phii u trong m(it cu(ic b5u cu mil t6i bi1t Ia minh kh ong h(ii du dibu ki~n. toi sc bi coi 13 ph1 m trong t(ii dp d(i 1.) IEilH~IJlf4: :.4>...\F.'Iilti&iE:f&!;l!;f"lZ~iiill~; ';1,:A.~'li!:i/JiJ'I.(;Ij*:(fJtt:):illl!l'Pl!!l'l <Uf§~ilill'l(
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last Name (Apell ido) (Ho) (/lt)
First N•me (Nombre) (Ten) (i\)
M idd le Na m e (if any) {Segu ndo nombre {s i t iene )
en dem (neu c6) <Pr.~,g
('51!)
(Ten cu) (~ ffli\)
Residence Address: Street Ad dress and Ap artme nt Number, City, Sta te , and ZIP. !f none, describe where you live (Do not include PO Box, Rural Rt. or business add ress) (Domlcl lio: calle y nUmero de apartamento, Ciudad, Estado, y
COdigo Postal : A falta de estos da t os, describa Ia localidad de su residencia. (No incluya el apartado de correos, camino rura l, ni directiOn comercial.)) (Dja chi cv trU : Ten dllb'ng va sO PhOng, Th3nh Ph6, neu Bang, va M:i Bllu Oien.
Neu khong c6, ,;n di~n tl nai quy vj ell ngv (K hong dll(1c de dia chi Hop Thll, Oia Ch i 0116-ng l ang hooc o;a Ch i Thl!ang M~i)) ~tf_l~II!: : ifii6ttt!II!:'f0i::V!;,~ · i(i · ffl'fO!l!lll!Hlb ~R • !l!J!)!;j;'>l" • ;~M~!ffialiRJl@(£~:lll; ( <.1o/JJll~<!l
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· ~?~~M~illili~illi~ltt41: J
Pine- Te.r-recc> Dr Ki hCjWvod\X 1-i:-3?J9
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Mailing Address: City, Sta te, and ZI P. If ma il cannot be delivered to your residence address. (Direcci6n postal :
Ciudad, Estado y C6digo Postal, si no es pos ible entrega rle corresponden ci a en su domidlio) . (Oja Chi GUi Thll :
Th3nh Ph0, Tieu Bang, va
Bllu Di~n. Nfu kh6ng thf ch uye n thll t6'i dja chi cll ngv cUa quy vj.) me~lfthl : ilJ ,
Gender : (Optiona l) {Sexo {Optative)) Gi6'i t inh:(Kh6ng
( O)ti'{~'FIJ'l)
b~t buoc ti~'J:
Ma
Date of Birth : M onth, Day, Year (Fech a de
nacim iento: mes, d(a, ai'lo)(Ng3y th<i ng nam sa nh :
Thang , Ngay, Nam)
tl:l!:EBWJ: ll · B · q:
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MaleD
Female!$"
(Hombre)(Nam)(~)
Check app ropriate box : Marque el
cuadro apropiado: E>:inh dAu vi10 6
thlch hQ'P :(f~ai/5l!lf"lill'J1:J :
TX Dr iver' s License No. or Personal I. D. No. (Issued by TX DPS} NUmero de
su licencia de conduc ir de Te xa s ode su cedula de ldentidad expedida por
el Departamento de Seguridad Publicu de Texas). SO B5ng l3i Xe cUa tie'u
bang Texas ho~c sO ID ca nhan (do B¢ An To<\n lao OQng tifu bang Tellas
(Mujcr)( Nii)(Y;)
Socia l Security No. (last 4 digits required if you do not have a driver's license or 1.0. number) NUmero de
Seg ura Social. (Sino tiene licencia de conducir ni identificac i6n person al, se requiere los Ultimos 4 nUmeros de
su seguro socia l) SO An Sinh
HOi (4 s6 cu6i cUu sO An Sinh Xil HQi din ph;li cO m! u qu'( vi khOng c6 s6 b~ng
xa
1it!t'l<i:'i1111i!!l ( jl(]!lHT:iHi.fallttM~Tf<fi!I),Jl'flliil!t)Jlli!!) • GIJ!Ji!IM±'I<-FQIJ;:
la i xe hole sol D ca nhan )
ARE YOU A UNITED
STATES CITIZEN?
ESTADOS UN IDOS'?) (QUY VI
KY KH6N G?) !~:Gl:!l'<!lll'"'l£'.~?
l~rves
(S;x)(il!:)
D
No
(No)(Khong){i!i)
•
0
Texas/Cedula de identidad personal de Te xas ni un Numero de
Seguro Social.) ( Toi chU'a he dU'c,YC cap bang (ai xe cua Te xas/so
ID ca nhan ho~c so An Sinh Xa Hoi.) W,)jfij TX W.ll<ril\~.\l !it}[U)lj/
fmi.A,!liB m!i!ltU!'J~H ~Hi':3':!i!lt lim
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HomePCT
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CERT/VUID
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Type of Election Tipo de Efecci6n
Hinh ThCrc Bau c~ il<lllll'ili:!
•
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0
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PCT
II
IJ59o
PCT
9-us-
NUm. de Precinto-lnscrito para votar/P han khu nai d3i ghi danh sO/iii~
~t)Jl.
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NUm. de Precinto -lugar de votaci6n/Phil n Khu nO'i dii B'au Clt SO/ili~~
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Date of El ection Fecho de Ia f/ecci6n
Ngav Bau c~ il!!ll El Wl
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FOR STATUS:
Au t hority Conducting Election Autoridad Adm inistrando Ia Eleccidn
Cu Quan Th6m Quyen Tiin Himh Biiu eli' ..±!.fJJI.MIJJIPI
BALLOT CODE:
L~ ;;L 11.i30__
{Write in t he Ballot Code, it is found on the Provisional Ballot Stub above the
l.
election day.
D YES
DVNO
2.
3.
4.
1.
5.
/
2.
3.
4.
5.
Vot ing after 7:00P.M. due to court o rder.
6.
election.
7.
8.
9.
Information on file indicatino aoolicant camoleted a voter reaistration
TO BE CO;\IPLET£0 BY VOTER: I am a registered voter of this pCllit ical subdi vis ion and in the precinct in which I'm attempting to vote and have not alreildy voted in this election (either in person or by moil) . I am a resident of
thi." polit ical subU ivision, have not been final ly convic ted of a felony or if a felon, I hove completed all of my punishment including any tenn of incarceration, parole, supervision, period of probation, or l have been pardoned. I hJvc
not bee n determined by a final judgment of a coun exerc ising probate jurisdict ion to be totally me ntall y incapac itatc::d or pania ll y menta lly incapacitated without the right to vote. I understand that giving false information under oat h
is a misdemeanor, and I understand that it is a felony of the 2nd dc:grec to vote: in an elect ion for which I know I am not eligible.
(PARA QUE El. VOTANTE LO LLEN£: Estoy inscrito como votantc en csta subd ivisiOn politica yen el prec into en cual cstoy intcntando a votary aun no he votado en esta clccci6n (en persona o par corrco). Soy rcsidcnte de
esta subdi\'isi6n politiCJ, no he sido definitivamcntc dcclarado cu lpab le de un deli to gr.Jve o si soy cl !iUior de: un de lito grave , he cumpl ido toda mi condcna inclusive cl periodo de encarcc lamicnto, Ia libcnad condicio nal, Ia lib enad
supcn·isada. Ia libcrta J vigilad a. o he sido indult ado, No me han dctcrm in ado por un juicio fina l de una corte de Ia lcgn lizac i6n de un tes1amento. scr totolrnentc in capacit::~do mento lmentc o parciahncnt e in c::~pac it::~do sin cl derecho de
vo~ar. E~1ti endo que dnr informaciOn falsa bajo ju ra me nt a cs un de lito mcnor y tamhiCn cnticndo que cs un del ito grave de 2do gr::~~o votar en una elccci6n sab ic nd~ que no c u~plo con los rcquisitos ncccsnrios.)_ (Ol/QC HOAN TAT
801 CU" TRI : TOi li1eli tri dil ghi danh b6 phic:u t(li phcin khu chinh tri dj.1 plnro-ng n:ly va trong phcin khu m6. t6i c6 y d!nh b6 phi Cu v:l chua b6 phi~u trong cuOc b:i.u clr n:iy (kC d d(ch thiin b6 phi~o hay b6 ph ie u bling thu). T6 i cu
ngv .tyi plyin khu chinh trj dja phuong nay: t ~ i hoim to~ n kh6ng_ bj k~ t trong tQi ho~c n~u 13 ngutii p_h ~m tn;mp tQi. t6i ~a hoil n thimh. h~t moi hin,h ph~t. baa g6~1 thOi h<;~~ tU ,_tm treo, qu:in cha. thOi kY thli thrich, ho~c dil dLtqc tha. r~an
quyCt cu6i cUng cim tOa ol n kh6 ng tuyCn b6 rtlng tOi Iii ng uOi mat hoim to:in nt!.ng h,rc ve m(i ttlim thUn hoy m5t mQ t philo nang lvc dC t6 i cO quyC n dugc b6 phiCu. T6i hiCu r~ng khai rn:m khi IU yCn th¢ se bj ph;;1m khinh tQi. vi t6i hiCu
r~ng n~u b6 ph i~u trong mQt cuQc b5.u e-li m:i tUi bitt 1a minh kh6ng hQi dU di~u ki~n. t6 i sl! bi co i l:i ph~m tn,mg tQi dp dQ 2.) EB~R:JUY;: ~A~ltti&~f5t'Ji~pqz-g-;~m~. 4i:A1nitmllf~j*=1frtt=~irH"UrflN~ (f~§~ID~nt
111.!1#) • 4>A!)frtif'J iM~~Z/iii~ · !t£51<fBl ·lC'IHii:~UiiiTiii:®Y,~JiO:Jil · !lK~n!Z\!11~'i'fiD:Ill · i§PiiW!11iin · §f<'iWiil';'; • 11\m · Wiil\l' · !1!Jf1JJ!;JEHt~iGII'~E.l&!!H~- • :4<At:E*111ii>l'lfl~5lb"olff Jig~q~)EfBlf>'/l 1 1 1 'i01o!iKffllf/)0~
'i<:lit:hH~!iiii!liil'(flil • :4<ABJliii;Ci[11Ht:~!JFFl'1~ll\!)~;nl · :ltiH>fE'JlJ"iJEic'fffg~jjHt:Jtlli;JtTifilHil'l'llli\'l~=~!Ufl:lll·
Last Name (Apellidol (Hoi lid:)
Middle Name (if any) (Segundo nombre (si t iene)
f\'{\~~\o
""Co~\~~
(TencOIIfllm:i'.)
Residence Address: Street Address and Apartment Numbe r, City, State, and ZIP. If none, describe whe re you live (Do not include PO Box, Rural At. or business address) (Domicilio: calle y nUmero de apartamento, Ciudad, Est<1do, y
C6digo Post<~ !: A f<~l t<l de estos datos, describa Ia local idad de su residencia . (No incluya el apartado de correos, cam ino rural, ni direcci6n come rc ial.)) (EJia chi cv trU : Ten dvOng va sO PhOng, Thilnh Ph6, Tieu Bang, va Ma Bll'u Oi en.
Neu kh6ng c6, xin d i~ n ta nai quy vi w ngv (Kh6ng dll<;rc de dia chi Hl)p Thll, Dia Chi Dllltng Lang hole Dia Chi Thllang Mail 1f5f!l~lll: : l!i:i'.filihl;f{J~li!~R · ifj · Hi'!U~'ilt!Ei~ • !l!JJ!!;ll# • ili5~tlllfJIIlJl@f!l~ll'.'; ( ID'io/Jflljj\
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Mailing Address : City, State , and ZIP. If mail cannot be delivered to your residence ad ess. (Direcci6n postal:
Ciudad, Es tado y COdigo Postal, si noes posible enlregarle correspondencia en su domicHio) . {Dia Chi Glti Thll:
Thanh Ph6, Tieu Bang, va Ma Bllu Di~n. Ne'u khOng th f chuyt?n thU' t&i dia chi ell ngv ella quy vi.) !fi~~~lll: : iTi ·
Gender: (Opt ional) (Sexo (Optative)) Gl&i tlnh:(KhOng
blt buoc tt~'l: ( DJIJijjK'fljl)
• !IIJJl!jj\'ilt!ii\;i;h'\il!!.TI(!';Jf.5f!l~lll: •
iii;f{Jjj\i\it;\1;~
Male D
(H om bre)(Nam)(!)J)
Check appropriate box: Marque r:J
cuadro apropiado: E>:lnh d.iu v;io 0
lh ic h hqp
Date of Birth : Month, Day, Year (Fecha de
nacimiento: mes, dia, aiio)(Ng~y thJng n~m sanh:
Thang. Ngay, Naml til~ 8 WJ : Jl · B · lJ'
:(fii'Jiii;Jj'jjiJ"JllJllt:J :
ARE YOU A UNITED
STATES CITIZEN?
ESTA DOS UN IDOS?) (QUY V!
c6 PHAJ LA c6NG DAN HOA
KY KHONG ?) !,l!JJ);~Ii\l~IX;n!.'\?
~
MYes
(Si)( C6)(Jl!-)
D
No
(No)(Kh6ng)li!ll
TX Driver's lice nse No. or Persona l I. D. No. (Issued by TX DPS) NUmero de
su licencia de conducir de Texas ode so cedula de ldentidad expedida par
el Oepaname nto de Segurid ad Publica de Texas). SO B~ng l ili Xe cUa tie'u
bang Texas ho~c sO ID ca nh5n (do BQ An To3n lao DQng tieu bang Texas
.
1
(Mujcr)( Nii)(:i{)
Social Secu rity No. (las t 4 dig its requ ired if you do not have a driver' s license or J.D. number) NUmero de
Segura Social. (Sino t iene licencia de conducir ni identificaci6n personal, se requiere los Ultimos 4 nUme ros de
su seguro social) SO An Sinh xa HQI (4 sO cu6i cUa sO An Sin h xa HOi c'a n phili c6 neu qu'( vj khOng c6 sO bang
Ii i xe ho~c so lD c3 nhan l
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Ut\H'~51!16!'l
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( !l!J!!!.TI;11'fli'l~t.AJ!!il!iKOO)..Jt(i)ll!~,~!!'l • ru'i1Ji1!JH±'Ii'-Fill:lt:
'
...
-
Texas/Cedula de identidad personal de Te xas ni un Numero de
Segura Social.) ( Toi ch11a he dliQ'c cap bang lai xe cua Texas/so
10 ca nhan ho~c so An Sinh Xa HOI.) 'JX)~~ TX ~!\Ttlt~SUtJilll/
OOA.!ti7HH51!1li!llmt±~3t-i:5b£li!ll •
Date of Election Fecha de Ia E/ecci6n
Nga y Bau cll illlll B WI
Female IJ.3"'""
Hom~PCT
D C> 2" cJ
I!H'i!ili:!\1
Precinct No. where registered _
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CERT/VUID
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NUm . de Precint o-inscrito para votar/ Phan Kh u nai
PCT
PCT
00~
NUm . de Prec into-lugar de votaciOn/P han Kh u nai da B"au CV 56/ffi~~
~-
da ghi danh sc5/ll!~
:lHi'.!ilill'6
FOR STATUS:
/, the voter registrar/deputy registrar, did research the records of my office and
BALLOT CODE: .l .Q
a ..1 Z Q. .1
1.
election day.
D YES
1.
~NO
~ailed to present acceptable fo rm of identification or voter
certi f icate with exemption.
2.
Voter m et disability exemption within 6 days of election day.
3.
4.
s.Z
2.
Voter not on list of regi stered voters .
3.
Voter not on list, registered in another precinct .
4.
5.
6.
election.
7.
Votin g after 7:00P .M. due to court order.
8.
9.
lnfnrmntinn nn fiiP inrlirntinn nnnlirnnt rnmniPtP rl n vntPr rPnktrntinn
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310784149
Declaraci6n Jurada de Votante Provisional I Ban Chtmg TM Cua Cu Tri T<:tm Thai I lfa~iiH~ :~U~:t:
TO B£ CO~I PLETEO BY VOTER: 1 am a registered vot er of this political subdiv ision and in the precinct in whi ch I'm attempting to vote ::~nd have not alre3dy voted in this election (either in person or hy mail). I am 01 resident of
this political subdivision. have not been linall y convic tccl or a ICio ny or i f a felon, I ha ve completed all of my pu nishment includ ing any term of inca rce ration, parole, supervision, period of prob:uion. or I have been pardoned. I have
not bee n determ ined by n fint:~l judgment of a court e;(c rcising prob:H c jurisdic tio n to be tot:JI Iy mentally incapaci tou cd or partia lly mentally inc apacitated without the right to vote. I understand that gi ving raise information under o<~t h
is a misdemeanor, anc1 I underswnd that it is a felon y oft he 2nd degree w vote in nn election for which I know I am not eligible.
(PARA QUE EL VOTANTE LO LLENE: Estoy in scrito como votante en e!-aa subdivisi6 n politica yen cl prccint o en cua l cstoy intentondo a votur y aun no he votado en est a elccci6n (en persona o par correo). Soy residente de
esta subdi"isi6n polit ico, no he sido dc fin it ivomc rll c dcclarado cu lpable de un de lito gra ve o 5i soy c l autor de un de lito gr:~vc, he cumplido toda mi condena incl usive cl pcriodo de encarcclamicnto, Ia libcnad cond iciona l. Ia libc rtnd
su pcrvisada. lu li bc n ad vigi lada. o he sido indu had o. No me han dctcrminado pa r un ju icio fin<~ I de una corte de Ia lcgnlizaci6n de un testamento. scr totalmcntc incapacitndo mcntnlmcn te o parcio lmcntc incapac itado sin cl dcrccho de
votar. Emicndo que dar in form aciOn lillsn bajo )uramcntn cs un de lito menor y tarnbiCn cnticndo que cs UJl deli to grave de 2do grLJdO volar en una clccc iOn sabicndo que no cumplu co n los rcquisitos ncccsa rios.) (DU'QC flO AN TAT
B(J1 elf TRJ : T6i lil ell tri dil ghi d:~nh b6 phiCu tQi ph<in khu cllin h tri dia phuang ntly v3 trong phJn khu m:i t6i c6 y djnh b6 phi~u va chua b6 phi~u trong cuQc b5u eli nily (k~ cil dich thJn bO rhi~u hay bO rhitu bimg thu) . T6i cu
ngv tyi ph<in khu chlnh trj diu phuung nUy, t6 i huiln loim khlmg bj k~t tn;Hlg t(li ho~c neu lit nguOi phtnn t rc,m~ tQi, tOi dii ho<ln thilnh h~t moi hinh phQI, baa g6m th&i h11 n 1U. fm Ireo, qufln c h~, th&i k)' thir th<ich, ho~c di\ duQ'C th<~ . Phim
quyet cu6i cUng cUa t6a ~n kh6ng tuyCn b6 rAng t6i lit ngubi m5t hoi:m toim nflng lvc v~ m~l tam th~n ha y miit mQt ph~ n nang lvc d~ t6 i cO quy~ n duQc bO phi~u. TOi hi~u rdng khui man khi tu yl:n th¢ sC bi ph;,1 m khinh tQi, v3 tOi hi~ u
r5ng n~u b6 phiJu trong mOt cuQc bUu cir m:l t6i bi~tl:l minh khOng hQi dUdi~u ki~n. t6i sC bi co i lil ph~m trQng tQi dp dQ 2.) El::lffi~;I.UT.~: :<fi:A1Mlti&;{5.~~r*lZit)~DJ~. *A:f=f~fm.§.Mj~~:trJlt.:.J.: UUlJrpfQj!,!! (~!!El~[~m.
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First Name (Nombre) (Ten) ('1\)
last Name (Apellido) (Hoi (tj:)
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0
Midd le Name (if any) (Segundo nombre {si t iene )
Former Name (Nombre anterior )
(Ten cu) (if! Ill~)
en dem (neu co) <Prc1'15 ( :S'il" )
...
&JIVJJ
Residence Address: Street Address and Apartment Number, City, State, and ZIP. If none, describe where you live (Do not include PO Box, Rural Rt. or business address) (Domici lio: calle y nUmero de apartamento, Ciudad, Estado, y
COdigo Postal : A falta de estes datos, describa Ia localidad de su residencia. (No incluya el apanado de correos, camin o rura l, ni direcci6n comerdaL)) (Oia chi cv trU: Ten dU'i:mg va sd PhOng, Thanh Ph6, Tifu Bang, va Ma Bllu men .
Neu kh6ng c6, xin dien ti nai quy vi w ngy (Kh6ng dlt<;rc M dia chi Hop Thll, Dia Chi Oltang Lang hojc Dia Chi Thllang Mail) IEI!It!!l.il: : Ui~ltt!J!:ffli}Ji<li,l · ifi · Jt!ffJID~liHlBii o ja]!l/,5)i 'ij" · ll/5ffllli.ll.'lllii!if1lltl!li ( iilo/JI!liD~
p.;Jf~lfi'mbl!i
ee
· :<119fjjlJi!~lifl~illl\\Vllil.il: I
7!00S
(Direcci6n postal:
Ciudad, Estado y COdigo Postal, si no es pos ible entregarle correspondencia en su domidlio). (Elja Chi Glti ThU':
Thanh PhO, Ti€u Bang, va Ma Bllu Dien. N€u kh6ng the chuyen thLJ t&i dja chi cU' ngv cUa quyvj.) !J!~*!llit:J.l: : iii ·
HT os~~ili!$81
6
1£1_
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bat buo)c tWJ: ( CJ l:l!~'fl):()
(HombreJINam)(!/5)
TX Driver's lice nse No. or Personal I. D. No. (Issued by TX DPS) NUmero de
su licencia de conducir de Texas ode su cedula de ldent idad expedida par
el Departame nto de Seguridad Publica de Texas). SO sang l;ii Xe cUa ti~u
bang Texas ho~c sO 10 cci nhan (do BQ An Tooin lao EJQng tiCu bang TclCas
nacimie nto: mes, dfa, aiio)(Ngay thcing nam sanh:
Thing, Ngly, Nlm) lfjg,_EJj\1): FJ • B · fJ'
Male 0
.
cu:Jdro aprop iado : E>fmh dfiu v:io 6
thich hqp :fr®'1tt1Jf'Ji*JJll1Ji:J :
Gender: (Optional) (Sexo (Optative)) Gi&i tinh :( KhOng
Female 0
(Mujcr)( Nfr)(:i(:)
Soc ial Security No. (last 4 digits required if you do not have a driver's license or 1.0. number) NUmero de
Segura Social. (Sino tiene licencia de conducir ni identificaci6n personal, se requiere los Ultimos 4 nUmeros de
su seguro social) sO An Sinh xa HOi (4 sO cuOi cUa sO An Sinh xa HQi c'an phili c6 n€u quy vi kh6ng cO sO bang
lai xe hole s51D ca nhan)
Hl\r""~l),~li'Ji ( !l!l*!$5li'il"l\'!~ti\!~Ji1Gii!IA~(lfm\'llibl!i • it11Jl! (!HiJi'-F®1JZ
ARE YOU A UNITED
STATES CITIZEN?
(i,SO Y CI UD ADANOIA DE LOS
ESTADOS UNIDOS?) (QUY V!
CO PHAI L , CONG DAN HOA
,) I[: Ji);:J<~ ~Ei:; U!!j?
0
(Si)( C6)(:li!:)
No
(No)(Kh<ing)(i'l)
.
Number. (No me han expedi9o una licencia de conducir de
Segura Social.) ( T6i chlla he dl!t;>c cap b~ng lai xe cua Texas/so
10 ca nhan ho~c so An Sinh xa H¢i.) r;:;.fi_:j;j TX !l'l~!f'W~~.mt'C ii!!j/
ft§J.A.!'l'M~51!tfilllg)(,Utr!i:i:5JJ16!!l
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Ngly Bau Coi ill!fl El WJ
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036/-
NUm . de Precinto-lugar de votaci6n/Phan Khu nai d3 sau Cti SO/iii~~
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CERT/VUID
PCT
County Clerk Use ONlY
PCT
_,---'';3"---'(o=----'\--=
NUm. de Precinto-inscrito para votar/Phan Khu ncti
da g;hi danh s6/DH~
!.iii'm. l'fSCII!!l!li
Hinh ThU'c Bau Cli illfllJ!:i~
FOR STATUS:
Authority Conducting Electi on Autoridod Administrondo lo Elecci6n
ca Quon Th6m Quyen Tien Honh Bau c.r ct·nilfMiitl/if
\-\-or(\S (auh ry
~\v1-b-
I, the voter registrar/deputy registrar, did research the records af my office and
BALLOT CODE: L
D
5. .8. S.-2.. Cj_ Y._ c::5
(Write in the Ballot Code, it is found on the Provisiona l Ballot Stub above the
1.
election day.
~·
1.
~
~led to present acceptab le form of identification or voter
cert ificate with exempt ion.
2.
3.
Voter executed religious objection affidavit within 6 days of election day_
4.
s.L
2.
Voter not on list of registered voters .
3.
Voter not on list, reg istered in another precinct.
4.
5.
6.
Nato registered voter or registration not effective in time for this
election.
cancelled mai l ba ll ot app lication .
7.
Voting after 7:00P .M . due to court order.
8.
Q
lnfnrrnntinn nn fifo inrlirntinn nnnlirnnt rnmnlotorl n untor roni<::trntinn
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311115520
Declaraci6n Jurada de Votante Provisional I Ban Cht'mg Th~ Cua Cu Tri T;:tm Thai I
li
TO B£ CQ,\ IPL ETED BY VOTER: I om o registered voter of this politico\ subdivision und in the precinct in which I'm anempting to vote and ha ve not alread y voted in this election (either in person or by mail). I am a res ident of
this politi ca l subd ivision , have not been finally convicted of o felony or if a felon, I have completed all of my punishment includ ing ony term of incorccration, parole, supervision, period of proba tion, or l ha ve been pardoned. I have
not been determined by a fina l j udgment of a court exercising probate jurisdiction to be totally mentall y incapac itated or partially mentally in capac it ated without the right to vote. I understand that giving fa lse informal ion under oath
is a misdcrncanor, and I unJcrstund thu t it is u fduny of the 2nd dcgn:c to vote in un election for which I know I om not el igi ble.
(PARA QUE EL VOTANTE LO LLENE: Estey in sc rito como \'Oiante en esta subd ivisi6n po litica yen d prcc into en cua l estoy intentando n votar y aun no he votado en esta elecci6n (en persona o por correo). Soy residcme de
est a subdi"isi6n pol it ica, no he sido dcfiniti va mentc dcclarado culpable de un de lito grave o si soy cl autor de un de lito gra ve, he cumplido toda mi condcna inclusi ve el pcrlodo de cncarcclam icnto, Ia libenad co ndic ional, lo Iibert ad
supervisa da. Ia libert uJ vig.ilada, o he sido indult;Jdo. No me han Uctcrm inado par un juiciu finul de una cone de Ia h.:gali:t.aci6n de un testamento , scr totalmentc im:a paci tildo mcntal mentc o parcia lmen tc inca pacitado sin cl dcrccho de
vo~ar. E,!ltiendo que dar informnci6n fal sa bajo juramenta cs un dclit o mcnor y tomb iC n cnt ic ndo que es un de lito grave de 2do grndo votnr en una clccci6 n snb icndo que no cu~plo con lo s requisites ncccsarios.) (D~'QC HOAN TAT
801 CU' TR I: TOi l:i ell tri dU ghi dnnh bO phiCu t ~;~i ph.in khu chfn h tri d ja phuong nil y v:i trong ph:in khu mn tOi c6 y Cl!nh bO phi~ u vil1.: hu::~ b6 phitu trong cu¢c bA u clr nily (kC c;i dlch thfm b6 phiEu hay b6 ph itu bflng thu). TOi cu
ng1,1 t~ i phtln khu chinh trj dja phuong nfly, t6i hmi n to:ln kh6ng bi ktt trQng tQi ho~c n~u 1:1 ngl!Oi ph<)m trQng tQi, t6 i dol hoan th~nh h ~t moi hinh ph~!. bao g6m thOi h\'n tU, dn treo. qu<in c h~. thOi k:Y thlr th<ich, ho~c Cl:l cJuqc tha. Ph<in
quy~t cu6 i cUng cUa t6a tin kh6ng tu yCn b6 r~ng t6i Iii nguOi m~t ho3.nto3n nilng Jvc v~ m~t t<'im thj n ha y mit mQ t ph!.n nang h,rc Cl~ t6 i c6 quy~n Clu(Jc bO phitu . Tdi hi~u r~ng khai man khi \UyCn t h~ sC bj ph\lm khinh tlji, vit tOi hi~u
ring ntu b6 phiiu 1rong m¢t cu<)c b& u cLr m; t6i bi~t Ia min h kh6ng h¢i du dilu kiin. toi sc bi coi 1; ph;lm lrQng tQi d p d¢ 2.) liiil!e\:fil~: *"-~1tt0Jti5n~,'F''lZ-tiii!;il!K *"-ll:li~.lll'l*:tfitt=J-:il!!ll<Pill:i':l (IJ'l@jjjl(oij;lf
Ill: ~~) · *"-~lttif.iiEiWJiiZ@!.\: · ltf*~lB'Ifffi~IHiiil&ili< 1r!JEm' · ~Wli:CtiJB'If!f!m' · ill.ffi.ffl!?.;;;J · E!li!i~;'?; · llfH'>l · 'iii'!lr · ll/JHJ~E.fll:'li:'ii:·\ll-~E.lffi!J1~ • 'i'A-ttE*ltHIJIJil~'llit;JftQt.HIUEI2lffl1~'Ji:3':~llilfi}!i<
5'<flt1Jilii!i\\lll:~,~lW • 'I'A'¥1W.:i1i:b'1Ji:tl1:HFF11!\'nRlM'J!i/E · ;t!zTII'II:E'Jl'«JEIC,l'H~i'iillfr'Jfllii>IT-1:Eill!l'l'i'tl!)l;IP.l=Mlili:!Jll•
last Name (Apellido) (Ho) (l&)
First Name (Nombrel (Ten) (;j';l
,;
Middle Name (if any) (Seg undo nombre (si t iene)
en dem (neu c61 'N•1,g ( ~'Jl I
:IAqU£/;~
ITen cG) (1:1 !ll:lS)
r
Residence Address: Street Add
and Apartment Number, City, State, and ZIP. If none, describe whe re you live (Do not include PO Box, Rura l Rt. or business address) (Domicilio: ca lle y nUme ro de apartamento, Cludad, Estado, y
C6digo Postal: A falta de estes datos, descri ba Ia localidad de su resl dencia . (No induya el apartado de correos, cami no ru ra l, ni direcci6n comerci al.)) (Oia ch i ell tni: Ten dvCmg va sc'5 PhOng, Th3nh Ph6, neu Bang, va M3 Bvu oien.
Niiu kh6ng c6, •in dien ta ncri quy vj w ngu (Kh6ng dl!Qc M dia chi Hop Thll, Oja Chi Ollang Lang ho~c Oia Chi Thllcrng M~i)) 16{1J~l.Jl: : {lj;j!;Jiti:Jl:fll0~1'i!'1 · ifi · jiif1l!m\1~Hlli9Jt • !IIJ!f-;Ji~· • :rtnf!m!JtHJlJ6{1~1!1'; ( ffi1o/Jfll[~l
~filffi~.~{lg
·
'tll~ l·~~;jl;fili~ilMR l~~t)
Mailing Address: City, State, and ZIP. If mail cannot be de livered to your res idence addre ss. (Direcc i6n postal:
Ciudad, Estado y COd igo Postal, si noes posible entregarle correspondencia en su domicilio). (O ja Chi Glti Thll:
Thanh Ph 0, Ti€u Bang, va Ma Bllu Oi~n . N€u kh6ng the chu yen thll t&i dja chi ell ng1,1 cUa quo( vj.) ffi~~filiJt : $ ·
JHftl~Bl!l!;ll;~R
Gender: (Optional) (Se•o (Optativo)) Gilrl tlnh:(KMng
b~t buoc 118'1: ( OJtl'l~l'lJO
Thang, Ng!y, Naml i:!J~SWJ: Fl · 8 ·lf-
• Jlii!l<illB~!!iiit~ili!&:n'JI@{±Jililii: •
MaleD
(Hombre)(Nam)(!Jl)
su llcencla de conducir de Texas ode su cedula de ld cntidad expedida par
el Depa rtamento de Seguridad Publica de Texas ). 56 B3ng Lai Xe cUa tieu
bang Te xas ho~c sO 10 ca nhiin (do BO An roan Lao OQng ti€u bang Texas
ARE
YOU
A
UNITED
STATES CITIZEN?
(;,SOY CIUDADANO/ A DE LOS
ESTADOS UNIDOS'!) (QUY VI
d
c6 PH AI LA CONG DAN HOA
~ 1a:~~::~?
(Si)( C6)(f;!;)
(No)(Khong)(i!l)
.
lai •e
Te xas/Cedtila de identidad perso nal de Te xas ni un Ntimero de
Segura Social.) ( Toi chlla he dllqc cap b~ ng lai xe cua Texas/so
ID ca nhan ho~c so An Sinh x a Hoi.) ~iiti'f TX Wli!'l' ¥M.~l!ltli!'li
@JJ,JH5JlR~Rli!'l~WHi~l!ltli!'l •
ho~c
..
so to ca nhan J
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lil!r'li:'3':'9R{ilg ( J!ll!.l!!G:':iJ!lllll$7fil!w.>l<illiA~~}ifi1Jfli!'l · ii'imf!H±'Ii.'-F®llt
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NUm . de Precinto·lnscrito para vota r/Phan Kh u na i a g
PCT
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NUm . de Precinto·lugar de votac16n/P han Khu na i daB
Hlnh Thlic Bliu Cv il!ll<lili!l:!
(M ujcrl( Nii)(:!l:)
Number. (No me han expedido una licencia de conduclr de
Female~
Social Secu rity No. (last 4 di gits requ ired if you do not have a d river's license or 1.0 . number) NUmero de
Segura Socia l. (Sino t iene llcencia de conduc ir ni identifica ci6 n personal, se re qul ere los Ultimos 4 nlimeros de
su seguro socia l) SO An Sinh xa HOi (4 sO cu6i cUa s6 An Si nh xa HOi din phil I c6 neu quy vi kh6ng c6 s6 b~ng
.
Dat e of Election Fecha de Ia Elecc/6n
Ngay Bliu Cit il!!!lBWJ
nacimien to: mes, dia, ai\o)(Ng3y thang nam sanh:
PCT
0
dan so/ fi!~
'1HcJttl!.5
FOR STATUS:
Authority Conduct ing Election Autoridad Administrando Ia Elecc/6n
Cct Quon Tham Quyen Tien Hanh Bau Cti cE#il!!JIIllil!
I, the voter registrar/ deputy registrar, did research the records of my office ond
the following conclusion(s) wos mode:
BALLOT CODE:
~Z~ Z6s-~~
(Write in t he Ballot Code, it is found on t he Provisional Ballot Stub above the
1.
election day.
VOTER PRESENTED ACCEPTABLE F~F IDENTIFICATION
L
_ [ , ,iled to
·
pce~ot:~,:p.,ble ;de~;~,.;oo
focm of
oc 'o"'
2.
3.
4.
Voter executed noturol disaster affidavit within 6 days of election day.
s.JL
2.
3.
Vote r not on list, registered in another precinct.
4.
7.
Registered to vote, erroneously fisted in wrong precinct.
8.
Q
fnfflrmntinn nn fifo inrl irnrinn nnnlirnnt rnrnnfotorl n 11ntor ,. .,,..; ~t rntinn
5.
6.
election.
.:'
.
--- · .
- - - - - - - - -- -- --
-
311122512
Declaracion Jurada de Votante Provisional I Ban Chtrng Th~ Cua Cu Tri T~m Thoi I ~~ill~J~. ~it
TO BE COMPLETED BY VOT£R: I arn a resistcrcd voter of this political subdivision and in the prec inct in wh ich r·m attempting to vote and hove not already voted in this elec tion (either in perso n or by mail). l <1m a resident of
this po litica l subd ivisio n, have not been fina lly convicted of a felon y or i f a felon, I have completed all of my punishment including any tcnn of incarceration, paro le, supervis ion, period o f probation, or I have been pardoned. I have
not bee n dete rmined by a fina l ju dgment o f a court exercis ing proba te jurisdiction to be tota lly me ni ally incapacitated o r partially mentally incapacita ted without the right to vote. I understand that g1ving f:J ise infOrmation under oath
is a misdemeano r, and I understand that it is a fe lony of the 2nd degree to vote in an election for which I know lam not elig ible.
(PARA QUE EL VOTANTE L.O LLENE : Estoy inscrito como vat ante en esta subd ivisi6n rolitica yen cl prccinto en cual estoy intcntando a votary aun no he votado en est a elecci6n (en persona o par correo). Soy res idenl c de
csta subdivisi6n politica, no he sido defi ni tivamcnte dcclarado culpab le de un de lito grave o si soy cl autor de un de lito grave, he cumplido toda mi condcna incl usive el periodo de cncareelam icn to, la libcrtad co ndiciona l. Ia libcnad
supervisada, Ia libcrtad vigilada , o he sido indultado. No me han dctcrminado por un juicio final de una co rte de Ia lcgalizaci6n de un testamento, scr totalmentc incapac itado mentalmcnte o parcialm ent c incapac itado si n el dcrcc ho de
votn r. Entie nd o que dar infomuc i6n falsa bajo jurame nt a cs un dclito mcnor y tambien cn tiendo que es un dclito grave de 2do grado votar en una clecci6 n sabiendo que no cumplo co n los requ isite s neccsar ios.) ( OU'QC HOA.N TAT
B()'l CO' TRI: T6i 13 eli tri cl ii ghi danh b6 phiCu t{l i ph:in khu ch!nh trj clia phuang miy v:l tmng ph::in khu m:lt6 i c6 y djnh b6 ph il:u v:l chun b6 phi~u tron1: cu{lc bfiu clr nily ( k~ eli dich than b6 phi~u hay b6 phi~u b~ng thu). T6i cu
ngv 1\)oi ph5.n khu chinh tri dja phuang n3y, t6i ho:in toim kh6ng bi k~tt rQng tQi ho~c n~u Iii ngui:Ji phQm tro np tQi. t6 i dd ho:i n thimh h~ t mQ i hlnh ph{lt , bao gbm thOi h~n tU , fi n trco, qu::ln ch~, thbi k)' thlr th::lch, ho~c d;l duqc tha. Phfm
quy~t cu6i cUng cUa tOo {m khOng tuyCn b6 r~ng t6i l:i nguOi mit ho~ n tofm n!ing h,rc v~ m~t tOm thfi n hay miit mQt ph5n n!ing h,rc d€ t6i c6 quytn duqc b6 phi~u. T6i hi~u r~ng khai mon khi tuyCn th~ se bj pho;~m khi nh tQi, v3 t6i hi~u
r! nH n~u b6 phiau trong m(i<cu(ic bdu cir mil t6i biatio minh kh6nH h(ii dir diiu ki~n. t6i sc bj coi io ph9m 1r9ng t(ii cftp d(i 2.) 83lll~J1U1l: :¥Al'liltl:'l:i5f/iCllii*!Z~iiillllk. :¥.A'l'ii'li!lii'iftr.ll*:tEilt'.XllliD'l'Jlti','l (fJ<EJ;j)G~~
t!!iWJ • :¥.AhJtti& iMt~rn;zgR · ~*llJ181'iiililJlliTijlf.tJ&t.t-lE>ll · ;j)GDIJ&:mm'l'iimw · ili!ffi#~iiij · §J2i!l<ft'i · ifm- !l<"N- !!1Jm~efii~:Jtl!l;j)Gelf.til!<f£ • :¥.A~;!<1&ll11Jil~m;t:fi1llm'&£rmm<J<:;t~*:lllf$f~
~{jg;I:Jiliif!i\ll!i!.'iHf • <I>:.ABJIIY.£r~l!<m!fJH tr 'mR~fl!;Jl · :lli7MtEOJl~Elc'fFJg;~tM"Jt.!lilLl'tEllllll'l'Jl!W?~=t.!Hlimt •
Last Name (Apellido) (Ho) (ttl
First Name (Nombre) (Te n) (~)
Forme r Na me (Nombre anterior)
Middle Name (If any) (Segundo nombre {si tie ne)
en dem (neu c6) 'l'fd];t ( :fi'ij)
( T encO)(ti/ll~)
Residence Address: Street Address and Apartme nt Number, City, State, and ZIP . U none, describe w here yo u live (Do not include PO Bo)(, Rura l Rt. or bu si ness address) (Domicilio: calle y nUmero de apartamento, Ciudad, Esta do, y
C6digo Postal: A fa lta de estes datos, describa Ia localidad de su residencia. (No incluya el apartado de correos, camino rural, ni direcci6n comercial.)) (Oja chi elf trU: Ten diJ'Cmg va sO PhOng, Thilnh Ph6,
Ba ng, va Ma Bvu Oien.
Ncu kh6ng c6, xin dien t! nai quy vic~ ngv (Kh6ng d~<;rc de dia chi Hop Th~. Oia Chi D~an g Lang hoijc O)a Chi Th~ang Mail) @(1lililli: : i!j~!fuJJI::[00lll'lJZ · i)i · iH:fU!m\'i!H'lillll • ~!!!ill# • ID'i~r.IDSliBJI@f1lilii!.l ( ID1o/.J/!l[~
neu
Fol i1Hfj')![6!!;.
Cf\JI\ V
'<1\ii·IISM!~ fm*ifll~'uiliJJI:)
t+av&-h fl 1 T. X -n 0 q if
W~ ~
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Mailing Address: City, State, and ZIP. If mail cannot be delivered to your residence address . (Direcci6n postal:
Ciudad, Estado y C6d igo Postal, si no es posib le entregarle correspondenc:ta en su domicilio). (Ella Ch i Glti Thll:
Mii Buu Dien. N~u kh6ng th~ chuy~n thlf t&i c1ja chi Cll ng1,1 cUa quy vi.) [~'ltiilii.tl: : ilJ ·
Thanh Ph6, Tie u Bang,
va
Gend er: (Optional) {Sexo (Optative)) Gi&i tinh:(Kh6ng
bl t buoc i18<J: ( P)'Jj'{;j)G'fiJO
Th ang,Ngay,N~m)l:!J~Billl:
• ~Jil,!ml'iltl!¥.~i.litli!&:e<Jf.!if±liliJJI: •
iH11JID~illli&51J!
Male D
(Hombre)(Nam)(!'IJ)
cuadro apropiodo: E>:lnh dju v3o 6
<hich hOP :tE~'Ii\1J~r'lili'J1:J :
TX Driver's License No. or Pcrso nai 1.D. No. (Issued by TX DPS) NUmero de
su lice ncia de conducir de Texas ode su Cl!du\a de ldentidad exped ida par
e l Departamento de Segurldad Publica de Texas). 56 B~ng Lai Xe cUa lieu
:
I
'
:
:
Date of Birth: Month, Oay, Year (Fecha de
nacimien to: mes , dfa, ai'io)(Ngay thang n~m sanh:
FJ • 8 · Jf.
Female~
(Mujer)( NilJ(:l>::)
Socia l Security No. (last 4 digits required if you do not have a driver's license or I. D. nu mber) NUmero de
Segura SociaL (Si no tiene licencia de conducir ni identificaci6n persona l, se requiere los Ultimos 4 nUmeros de
su seg uro social) sO An Sinh xa HOi (4 sO cuOi cUa sO An Sinh xa HQi dn phi31 c6 neu quYvi kh6ng c6 sO bang
•
't1 • ~
tl.!i •I.
. ; ~fl . i ~J .. li : '. r,j{ ~
,; ~
{(;
ARE YOU A UNITED
STATES CITIZEN?
(LSOY CI UDA DANO/A DE LOS
ESTADOS UNiDOS?) (QUY VI
KY KH6NG'!) !,2H~~~~l:l::PJ~?
0
'0ves
(S~C6)(Jll.)
No
(No)(Kh6ng)(i§)
D
:
•
Te xas/Ced uia de identidad perso nal de Te xas ni un Numero de
Seguro Social.] I T6i chlla he c!ll(fc cay bang lai xe cua Te xas/so
iD ca nhan ho~c so An Sinh Xa Hoi.) '!Jti~'l'l TX ll',l!\1:%1\~IJ!Xi)!jl
li.A.!itMM!~i)!jJl'ZtHHc:'EIJ!Xi)!j
•
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Ngav s~u cit
BWJ
I' I
I have not been issued a TX driver' s license/
Home PCT
County Clerk Use ONL Y
0
NUm. de Precinto-lugar de votacl6n/Pha n Khu ndi dii sa u Cit SO/fii{gtii
')![ tltmlilil!l'i
CERT/VUID
Per
Vater Rrgistrar Use ONLY
Precinct No. where registered-----.,------:=
NUm. de Precinto-inscrito para votar/Phan Khu nO'i da ghi danh sO/»!~
!lii'l!Z. '>l:oclilim'i
Type of Elect ion Tipo de Elecci6n
Hinh ThU'c Bliu Cit lllWl:lill:!
FOR STATUS:
Ccr Quan Thdm Quyen
nen Himh Bau cv I/ifif!Mt/1/P!
th e following conc/usion(s) was mode:
88
BALLOT CODE:
(Write in th e Ballot Code, it is found on the Provisional Ballot Stub above th e
l.
election day.
DYES
1.
~ailed
Pll_NO
to present acceptable form of identification or voter
certificate with e xemp tion .
2.
3.
4.
5.
z.
Voter met disability exemption within 6 days of election doy.
3.
Voter executed religious objection affidavit within 6 days of election da y.
4.
5.7
FOR VOTERS WHO VOTED PROVIS/ONALL Y FOR OTHER REASONS
6.
election.
7.
8.
9.
lnfnrmntinn nn fi /p inrJirntinn nnnlirnnt rnmniPtPrl n
11ntP r r Pn i c::trntinn
I
---------------------------------------------------Case 2:13-cv-00193 Document 737-5 Filed in TXSD on 11/17/14 Page 36 of 83
1111111 1111111111111111111111111 1111111111111111111 1111
310903537
Declaraci6n Jurada de Votante Provisional I Bim Chtmg TM Cua Ctr Tri T~m Thai I lfa~ill~~~-
TO BE COM PLETED BY VOTER: I am a reg istered voter of this politicn l subdi vision ond in the preci nct in which I'm attempt ing to vote and hnvc not already voted in this elect ion (either in person or by mo il) . 1 am a resident of
th is pol i1ica l subdivisio n, have no t been fin a ll y convicted of a felony or if a felo n, I have co mp leted all of my puni shment including any term of incarce ration, paro le, supervis ion, per iod of probation, or I have bee n pardoned. I have
not been det ennined by a fin al judgment of a court exe rcising probate jurisd ict io n to be totally mentally incap:lcit atcd or pania ll y ment ally incapac itated wi thout tht: right to vote. I und~: rsta nd that giving fa lse in fo rmation under oat h
is a misdemea nor, und [understand that it is a fd ony of the 2nd de g re ~ to vote in on elect io n for whic h I know [am not e li g ibl e.
(PARA QUE EL VOTANTE LO LLI::NE: Estoy insc rito como votnnte en csta subd ivisi6n pol!tica yen cl prccinto en cua l cstoy intcnta ndo o votar y aun no he votado en esta elecc i6n (en pe rsona o por corrco). Soy residente de
esta subdi visiOn politica, no he sido dcfin it ivamcn tc declarado culpable de un delito grave o si soy c l aut or de un delito grove, he cumplido toda mi condena inclus ive el periodo de cnca rce lami cnto, Ia Iibert ad condiciona l, Ia lib crt ad
supc rv isada, Ia Iibert ad vig ilada, o he sido indu!tado. No me hun dctermi na do por un juicio fin:JI de una cort e de Ia lcgaliza ci6 n de un testomento , scr totalment e incapae it ado mcnt almente o parcialmcnt c incapac itado sin el dcrecho de
volar. Enti endo que dar informaciOn falsa bajo juramenta cs un dclito mc nor y tarnbiCn cntiendo que cs un delito gm vc de 2do grado vo tar en una clccci6 n sab icndo que no cumplo con los requisites necesarios. ) (DU"QC HOAN Tkl'
BOI c lJ' TRJ : T6i til clr tri di'i ghi danh bO phiCu IQ i phlin khu ch ln h tr j dja phuong nilr va tro ng ph:ln khu rna tOi c6 y d jnh bO ph i~ u vii chua 00 phi~u trong cuQc bAu eli ncly (k~ ca dich th3n bO phi! u ha y b6 phit u bi.ng thu"). TOi Cli
ngv .t~i p~J. n khu chin h trj d j:J phvcrng nily: t~ i hocl n toDn khOng. bi kc5 t tro ng tQi ho~c nCu ta nguUi P.h1.nn lrQ n~ tQi. t6i ~;) hoiln th3nh. hc5t mo i hin.h ph\lt , bao gb'!l thOi h ;t~ tU ., an trco, qucin chC. thUi k)' thlr th3c h. ho~c da dli<;rc th.a . P~iin
qu yC t cuOi cUng cUa tOa :i n k:h6ng tuye n bOding t6i Ill ngu&i mtit holln toa n nt'l ng lt,tc v~ m~ t t:i m th5n h;;~y m:lt mQ t phfin nnng lvc dC tO i c6 quyCn dliQC b6 phie u. T6i hieu rang kh :Ji man khi tu yCn the sC bi phym khinh tQi. vil t6i hiCu
ri. ng n ~u b6 ph i~u tro ng mO t cuoc bi u cir rn; t6 i bi ~ tl; minh kh6ng hr) i du diiu ki¢ n. to i sc bi coi 1; phQrn IIQng <oi dp do 2.) El3iliR:ltit;!: ;$:J..!}Jltil!{o5fOI&F'lZ~otiliR:. ;$:}..'/j:ftfili.ll. (l;l*:(fJlt:);:ilil!l'PiG:i\!1 <fJ! § !iliX~>'f
t!l:J.'ii • <li:J..&\Jlti&i5W!';z ~ R: · t;N<tlil.m~!I!:Wmiil\ii;t;~;Emt · ~~HO f:HHrl'll!T.!mt · !§1'1i~!!\n.J · E!~i<Jr; · 11\lfl! · llii'll\' • t!!iflJJ!'; E tli:lt:rtli!Y.XEll>~*. • ~'.A.i.:t*ll>ill'il~l.l!itli!J&m~lEffil:fflli!J>t~Y.Xflf\ISW
!l.:fiE.!J ffiji!\\!J!lllif!l • <li:J...BJli~lfit'ftt:!JlHFF't:IJ'l'iR&Ifl!ill · M<TM:(fljfjJD§ c1'f.J~J'l'tllft:J1l!lillTifill l!l 'PtJ!lW~=t&lf!11\ •
First Name (Nombre)(Ten) (:8)
last Name (A pellido)(H Q) (!1): )
en dem (neu co)
Former Name (Nombrc anterior)
<Prdl:t ( '15'/if I
(Tencu) ( \';1/!l;IS)
13 r owtl
Residence Address: Street Address and Apartme nt Number, Ci ty, State , an d ZIP. If none, describe where you live (Do not incl ude PO Box, Rural Rt. or business address) (Domicilio: calle y nUme ro de apartamento, Ciudad , Estado, y
C6digo Post al: A falta de estos datos, describa Ia loca lidad de su rcside ncia. (N o incluya el apartado de correos, cam ino rural, ni direcci6n comerci al.)l (Oja chi CU' trU: Ten dvbng v.l sO PhOng, Thanh Ph6, lieu Bang, va Ma Bvu Olen.
Neu khong co, xin di~n ta nai quy vi
w
· ill · HI'!U ffillllt~i\£ • jliJ~o!.Fif · m'i~!llilli8JJ~ (±Jt!::&i ( ID'J o/JI!liF!I
ngu (Kh6ng dllac d~ dia chi Hr) p Thll, !lla Chi !lvlmg Lang ho 3c !lia Chi Thvang Mii)) @(±lttlii: ; tlj:8Jt!:JII::[Oi}!ii~R
IO] {g'ffi jCili!!j . ~ ? f i'3t\!:8 fjlj ;;XJ!li>Cilt!!!Jl: )
;l3o<1
whe-e.lw
AP~
I )( I
Date of Birth: Mo nth, Day, Year (F echa de
naci mi ento: mes, dia, ano)(Ng.'ty th3ng nam sanh:
Mailing Address: City, State , and ZIP. If mail ca nnot be de live red to your residence address. (Direcci6n pos tal :
Ciudad, Estad o y C6digo Postal, si noes posi ble entregarle corres pondencia en su domici lio). (O ja Chi Glti Thv :
Th.lnh PhO, Tieu Bang, va Ma Blfu men. Nf u kh6ng the chuyen thlf t6"i dja chi Cll ngv cUa quy vi.) !lll!W.fl!!..f:.lt : flj ·
Thang, Ngay, Nam)
• !4J~!tlllll'f!\\$ Uli:l! !a:(!\J~ (±lt!!lJJ: •
i·lifO ffilli!UlPi~i
Male ~ Female D
(Hombre)INam)(!/l)
Check appropriat e box: Marque cl
cuadro apropiado : D:inh d~u vao 6
thich hQP ifiii'M/J~F'lJrrlJ1:]
;
ARE YOU A UNITED
STATES CITIZEN?
(;.SOY CIUOADANO/ A DE LOS
ESTADOS UNIDOS'!) (QUY VI .
C6 PH A I LA C6N G DAN HOA
KY KH6 NG'!) !~~~~0.B':II.~ ?
~s
DNo
(No)(Kh6ng)('6)
(Si )(C6)(fl!:)
TX Driver's license No. or Personal I. D. No. (Issue d by TX OPS) NUmero de
su licencla de condu cir de Tex as o de su cedula de ldent ldad expedida por
el Departamento de Seguri d;;~d Pu blica de Texas) . s6 B3ng La I Xe cUa tieu
bang Texas hoijc sO 10 ca n h~n (do B() An Toan lao OQng tieu bang Texas
.
Segura Social.) ( T6i chua he dU'Q'c.cap bang lai xe cua Texas/so
ID ca nhan ho~c so An Sinh Xa H(ii.) tti3.fl' TX M!llftt\~.?. si11!i!ll/
I~Am5H!H111 6!!l~t±t''te~ !t.H'!!i •
ta i xe hole
.
-
-
lHHi':i:'lllli!!i ( jz[)~ !a.:iJl.'llm ~tlli!\l;j11ffilJ..!r {J)llUi!li!!i · li!i!JiH!H±'tf-Filll!
.-
HamePCT
OZ.10
~.¥. iJ!~ilt!: :&i
CERT/VUID
Precinct No . where registered
.
.
.
.. .
..
' .
PCT
County Clerk U.se ONLY
0210-1
02JO
NUm . de Precinto- lugar de vota ci6n/ Phan Khu nai da B3u Clr 56/ llHHi~
11/5113
so10 ca nhan)
X
(Mujcr)( Nil)(:!()
Social Security No. (last 4 digits required if you do not have a dr ive r' s license or 1.0. number) NUmero de
Segu ra Social. (Sino t iene licencia de conducir ni identificad6n personal, se requiere los Ultimos 4 nUmeros de
su seguro social) SO An Sinh xa HO i (4 sO cu6i cUa s6 An Sinh xa HOi can phoii c6 n€u quy vi kh6ng c6 sO bang
.
Dat e of Election Fecha de Ia Elecci6n
Ngay B1iu cu- ili<llBIVl
tll':ESIVl : FJ • 8 · ~
Voter Registrar Us~ ONLY
PCT
0 Z l0
NUm. de Precinto-inscrito para votar/ Phan Khu nai da ghi danh s6/ill:~
!lii'll!. :IHcJttl!ll
Au thority Conduct ing Elect ion Autoridad Adminisrrondo Ia Elecci6 n
Hinh Thtic Bau cu-
ccr Quan Th6m Quyen Tien Hlrnh Bau Cti .:J:J 'lilfii!/Jf/Jlf
Uil!l'l!a!l!i
FOR STATUS:
~CUr(': s G, {,t,V\..-{,
I, the voter registrar/deputy registrar, did research the records of my office ond
the fo/l~wing conclusion(s) wos made:
BALLOT CODE :
l_ q_ 2.ld .l ~ Q ~ 3--
(write in the Ballot Code, it is found on the Provisional Ballot Stub above the
voter's signatu re area. The Provisiona l Ballot Stub is generated from the JBC.)
1.
election day.
l.L
D YES
~0
Failed to present acceptable form of iden
2.
3.
4.
5.
2.
3.
4.
s.L
Voter did nat satisfy identification or affidavit requirements, listed in
6.
election.
7.
B.
9.
Informa tion on file indicating applicant completed a voter reqistratian
!!IJ!IJ i!lll lll llll lllll lllll l llllll lllll l l l/1111
310903564
Declaraci6n Jurada de Votante Provisional I Ban ChU11g Th~ Cua Cu Tri T~m Thai I lfn~ii~JUs :fi
TO BE CO;\IPLETE D BY VOT ER: I am a registered voter of this politica l
the p
I' m anempt ' to vote and ha ve not already voted in th is elec tion (either in person or by mail). I am a resident of
this political su bll iv isio n, have not bee n fin all y co nvic ted of a felo ny or if a felo n, I ha ve comp leted all of my pun is hment includ ing any term of incarcerat ion, pa role, su pervis ion, period of proboll io n, or I have been pardo ned. I ha ve
no t bee n determ ined by o fi na l judgment of n court exercising probate jurisdi ction to be totall y mcntu!ly inca pacitat ed or part ia ll y mentilll y incilpac itat cd wi thout the right to vote. I understand thut gi vin g false information under oath
is a mi sllcmcanor, anlll um.J erst and that it is a fel ony of the 2nd dt:grec to vo te in an t.: h:ction for which I know I am not c\igibl t.:.
(PARA QU£ EL VOTANTE LO LLENE: Estoy inscr ito como votantc en esta subdi vis iOn politi ca yen el prec into en cual estoy intc nt ando a votary aun no he vo tado en esta clecci6 n {e n pe rsona o por co rrco). Soy res ide nt c de
es ta subd i"isiO n po litica. no he si do dc fin it ivamcnt e dccla rado culpab le de un del ito grave o si soy cl uuto r de un deli to grave, he cump lido to da mi co nd cna in clusive d pcriodo de cncarcc lam icnt o, Ia libcr1nd condiciona l, Ia libcr1ad
supcr\'isadn. Ia libcn ud vit; iluda. o he sido indultado. No me ha n dctcrm inudo por unju icio final de una co lic de lo lc gn liza ci6n de un testamento. scr tota \mcnt c incnpoci tado mcnto\rncntc o parci:J irncnt e incapu citado sin cl dcrcc ho de
\'Oiar. Enticnd o que dar informaci6n fal.sa buj o juramenta cs un ddilo mcnor y tambiCn cnticndo que cs un delito grn vc de 2do grado volar en una clccc i6 n sabicndo que no cumplo con los rcquisitos ncceso.rios. ) (DU"QC HOAN TAT
B( )'J e lf TRI: T6i l:i clr tri dil ghi danh b6 phiCu t~ i phil n khu chinh tri dja phuang nay va trong ph:in khu rna t6i c6 )i djnh b6 phi~u vi chua b6 phi ~u trong cuQc b5u eLi rul y (k~ d dich thfin bO phi~u hay bO phi~u bftng thu) . T6i cu
ngt,ll :;! i ph:in khu chinh tr j d ja phuon g nay, t6 i ho3n to ;ln kh6 ng b! !o:Ct trc;mg t(li ho~c n~u Ia ngu&i ph~m lr~ng tQ i. t6i dfi hoil.n th:inh h~t mQi hlnh ph:;~t. b:.o gbm thOi h;;m til , an !reo, qu:in ch~. thlri kYthlr th:ich. ho~e di'i duqc tha. Ph;ln
q u y~t cu6 i cU ng cUa t6a an kh6ng tuyCn bb r~ng t6i loJ ngu6i m~t hoa n to:in nilng h,re v~ m~t t:im t h~n ha y m~t m¢1 phAn nang lt,Ic d ~ t6i cO quy~n duQC b6 phi~u . T6i h i~u d ng khai man khi tuyCn th~ s~ bj ph;;un khinh t¢ i, va uli hi~u
r~ ng n~u b6 phi~u trong m(> t cuQc b:iu t:lr ma t6i b i~ tl:i mlnh kh6ng hl,l i dUd i~ u ki~ n . t 6 i s~ bj coi 1:1 ph~;~ m trQng tQi dp dQ 2.) d:~ }E~!jl~: ~i:)...~llti&:~~t§:~I*Jzfr;l;ll!B:, *A*=Ht»filit'o'j*-:f:Edt=.Xillalrf"ltfr!!U (¥fl r;l !ft!fiF>*
N.l'il) • >I• AMt if.!CMJ: rn; zg ~ · li't:*IEllllJ'iiilllJJ1fll11/!il&!%lEO!l · ~~eniHHll'i;lll{:ll' · I§P!i'i;lil:lli'l · '§tliiiii:fl: · 11'11'11 · ~tl · tiilf'i~"J E.Ilt~i:>i: ~:!!XE?l>iiJI:~ • 'I'A ii't:*lliimll~ i.l!itlf! liW!'/i(li': !El t~l•l•i<i3tW<illll7lW
'H'EtJ iliii!\\lll.i'iHM • 'I'.A.'!JlAli!:§:fH!i:IQ IJ.t'F 'l'!l"i:R~ i'l!go · :JETI41flfDJI J:!JEI 2'Fffi>l"i~fi':Jtillill.Tlfill!!l'i'll!\'ii: l!l= W.!ll.!lll ·
First Name {Nombre) (Ten) (:t)
Last Name (Apellido)(Hol (!ttl
Name (if any) (Segundo nombre (s i tiene)
dem ln eu co) <Prn1~
Name {Nombre anterior)
( :5''11)
cu) (\\1 /ll:l',)
Residence Address: Street Address and Apartment Number, City, State, and ZIP . If none, describe where you live (Do not include PO Bo)(, Rura l Rt. or business address) (Dom icilio: calle y nUmero de apartamento, Ciudad, Estado, y
C6digo Pos ta l: A fa lta de est es datos, describa Ia loca lidad de su residenc ia. (N o inc luya el aparta do de correos, cam ino rural, ni direcci6n comerc ial. )) (Oia chi cu trU : Ten dub ng va sO PhDng, Thanh PhD, Ti€u Bang, va Ma Bllu Oien.
Neu khiing c6, xin di~n ta no\ quy vj Cll ngu (Khiing du<;lc de dja chi H(ip Thu, Oj a Chi Oui:Yng la ng ho~c Oja ChiThuong M9i) ) mi±Jt!:IJI: : lJj~J\!ilJI:W0WlR · ffi · jij f{l ~f,i:f [J1!W£ • !l!JJT!;l( H" • l~~WifJtlj)Jii![(1 Jt!:!!l5 ( li'lo/)Jfl!ijl
Fuli1Hi'i~Rii!'.l
·
l<Jl9~1-3i!il~fJil!i'<illi91lll!!lJI:
I
Mailing Address: City,
Ciudad, Estado y C6digo Postal, si no es posible entregarle correspondencia en su dom ici lio).
Thanh Phc5, Tieu Bang, va Ma Buu oien. N€u kh6ng the chuyen thll t&i dla chi cv ngv cUa quy vj.)
JH fll~l:i!'l l§'i!Jt
nacimiento: mes, dia, aiio)(Ng3y thcing nam sanh:
b~t bu(ic 1'£~1):
Thjng , Ngay, Nam) til~ BWJ
• !lO M/o ffill'iJH~>tiililli!.1:fi':JI§ I±lltl!t •
Male ·~ Female D
(Hombre)(Nam)(!IJ)
uppropria1l.: box; Marqul.: cl
cuo.dro apropiado; D<lnh ddu vilo 0
thich hqp _TI: ill il'; :IJ~P'IIll•J t:J :
: Fl · B · "!'
TX Driver's license No. or Personali.D. No . (Issued by TX DPS) NUmero de
su licencia de conducir de Texas od e su Ct?dula de ldentldad expedida par
el Departamento de Seguridad Publica de Texas ). sO BAng L3i Xe cUa tieu
bang Texas h o ~c s6 ID c3 nholn (do BQ An Toan Lao OQng tieu bang Texas
(Mujer)( Nfr)(:t{)
Socia l Security No. (last 4 digits required if you do not have a driver's license or 1.0. number) NUmero de
Segura Social. (Si no tlene ilcencta de conduc lr ni ldentificaci6n personal, se requiere los Ultimos 4 nUmeros de
su seguro social) sO An Sinh xa HOi (4 s6 cuc5i cUa s6 An Sinh xa HOi dn phal c6 nfu quy vi khOng c6 sO bang
lai xe ho~ c
s6 10 ca nhan)
i!I!J3f3t'l.~li!!l
( !lll!T!!.1:iJ!J'ii!'ll!!l!tll~~II!IA!l-illlll'l,Vi!!l • llil1EIJH±3f·i<liHlt
ARE YOU A UNITED
STATES CITIZEN?
(iSDY CIUDADANO/ A DE LOS
C6 PH A I LA C6NG DAN HOA
KYz~~::·~ ?
PCT
Date
Elect ion Fecha de Ia Elecci6n
Ngay Bliu Coi
ill$ B WJ
NUm. de Precinto-lugar de votaci6n/Phan Khu nai d3 B"a u Clt 56/ ffi ~~
OliO
wt. ll!lWJt!:i!\1
CERT/VUID
Precinct No . where voted
u(s\ I?
D~ \ '{)
!lii'l!/. ft;i'.li!!!ll
Hlnh Thlic Bau Coi il!l!ll'@~
PCT
8-5 I /035
NUm . de Precinto-inscrito para votar/ Phcln Khu nO'i d3 ghi danh s6/illi;g
Type of Election Tipo de E/eccicin
02.10 - /
VoterRr:glstrorUse ONLY
FOR STATUS:
Authority Conduct ing Election Autoridad Administrondo Ia E/eccirin
Cct Quan Th6m Quyen Tiin HOnh SOu Cti I /i¥ifii:IJ11tli lf
Ci~f)~
I_ the voter registrar/deputy registrar, did research the records of my office and
BALLOT CODE:
l 1._).. C{tf_ l7_ j_ ~
1.
Voter presented acceptable form of identification with in 6 days of
election day.
1. /
'"~"'~~'~'""' ~'~'~"''"
'"''' to
fmm
2.
3.
4.
5.
""'"
Voter on li st of people who voted early by mail, and voter has not
2.
3.
4.
s.d
6.
election.
7.
B.
9.
Information on file indicatina aoolicant com ole ted a voter reaistration
'•'
-
- - - - -- - - - - - - - ----
- ---- - - - --
- - ··
l lllllllllllll lll310903573
llll l lllllll lllll l lllllll llll
Declaracion Jurada de Votante Provisional I Ban Chtmg Th~ Cua CLr Tri T<;tm Thai I ~~ili~~~:S
TO BE COMPLET ED B Y VOT ER: I am a regi.c;;tcrcd vote r o f th is pol itical subdivisio n and in the precinct in whic h I' m auc mp ting to vote and have not a lready voted in th is elect io n (either in person or by mail). I am a res ident of
this political subdiv ision, have not been fi nally co nvicted of o felony or i f a felon, I have completed all of my pun ishment including any ter m of inca rceration, parole, su pervisio n, pe riod of probation, or I have bee n pudo ncd. I have
not been dete rmined by a fi nal jud!Jme nt ofu court exerc ising probate jurisd iction to be lOt all y me nta lly incapaci tated or partia lly menta ll y incnpac itatcd without the right to vote. I understand that giving fa lse in fo rmation under outh
is a misdemeanor, and I undcrstamJ that it is a felo ny of the 2nd degree to vote in an elect io n for whic h I know I am not el ig ible.
(PARA QUE EL VOTANTE LO LLENE: Es10y in sc rito co mo vo tantc en csta subdivis iOn pol itica yen cl prcc into en cual estoy im cnt ando a volar y aun no he vo tado en esta eleccitln (e n persona o po r co rreo). Soy resiLic nt c dt:
csta subd ivisi6n polilica, no he sido dcfiniti vamcnt e decla mdo culpab le de un de lito grave o si so y cl autor de un dcli to gra ve . he cumplido toda mi condena inclusive c1 periodo de cnca rcclnm ic nto, Ia libe nad eo ndicional, lil libcrtad
supcrvisild<l , Ia libert ad vigi [ada, o he sido induh ado. No me han detcnnin ado po r un juicio final de una co rt e de Ia J cga l iz <~ci 6 n de un testamento. ser tOtillmc: nt e incapacitado me ntahneme o parcialmentc incnpacit ado si n cJ dcrccho de
vo t::.r. Entic ndo qu e dar informn c i6n fnl :;a bnjo )urn ment o cs un de lit o me nor y tambi Cn entiend o que es un de lit o gfilvc de 2do grade votar en una elccc i6n sabi cndo que no cumplo con los requisites neccso.rios. ) (OU'QC HOA.N T kf
8(11 C lJ' TRI: TOi hi clr tri dU ghi dnnh bO phicu t\li ph5n khu chinh trj dj"' phuong m'l y vii trong philo khu mil t6i cO y ll jnh b6 ph iCu vOchm1 bO phi~ u tron g cuQe bbu clr nily ( k ~ d dieh than bO phi~u huy bO phi6u biln g thu). TOi Clt
ngv t\l i ph;i n khu chinh tri dia phuang n.l y, t6i ho:l n lo:i n kh6ng bj kC ttrc;> ng tQi ho ~ c n~u lil nguUi phym trC)ng tQi, t6i dJ ho.l n thil nh h6t moi hinh ph;;~t , bao g6 m th &i h:;111 tU , il n trco, qu.ln eh~. th&i k)' thlr thilch, ho~c dll duQC thu. PhOn
qu y~ t cut\i cUng cUa t6a <in kh6ng tuyC n b6 rAng t6i ).] nguOi mAt ho.l n toim nl'in g lve v~ m~ ttci mt hAn hay m~ t m¢1 ph~ n nfmg tvc d~ t6i cO quy~n du~;Je b6 phi6u. TOi h i~u dng khai mta n khi tu yCn th~ s~ bi ph;un khinh t¢i. v:l t6i hiCu
rjng niu b6 phitu trong m{>t cu1k bi u ct! m6 t6 i biit Ia mlnh khong h{> i du d i~u ki ~n. toi se bi co i 1; ph1m trQng t{> i d p d¢ 2.) Hlil!RIJ1R ;f;:),.ll,Jttiaifoili[ll;l"lZS;'i!;ill~ . :<$:},.1l:i\!llJl.Elf;\j*1'£1tt'.7:illl!WtliiW (iJII3!i~[<f,\.'f
tll~,'ll • :4<)..1!:1Jtt i5Ut.or.;~zll!i~ · tUI&JG#!Il::WITWii%/Nml:iJil • i!.!WIIf~l!liJe1lillmi • illlfr'1>1~ii;J · @.l'ii'!.i!i'o · fi~r~ · l'llitf · ~!flJI"JE'.Ill~7\'.·~·!i~E'.lt'<W!t!t • ;t;:J,.~*I!Iiit;l!l4~ii!liii;/f.!INW&lEI&Il'J1t~%1':wUll\1li~
9.:ttd:1Jffii.J!l(tlil'litll • ;t;:J,.Hf!H.~}[i!f 1t:t!fi!H'L'fj!llR1i:lmti · ;lli""TM1flif!W El E'.1'1:tS~I1!r81>~>~T:tfllJ!!<<Nlil!lllilJ=ill !TI!Jll •
Middle Name (If any) (Segun do nom bre (s i tiene)
en dem (neu c6) <Pra~ ::l\ (:iii~)
Fi rst Name (Nomb re) (Ten) (~)
last Name (Apel lido) (H Q) (!It)
fTen cu ) (li)l!l:l', )
Residence Address: Street Address and Apartment Numb er, City, State, and ZIP.If none, escribe where you live (Do not include PO Box , Rural Rt. or busine ss addre ss) (Domicilio: calle y nUmero de apartamento, Ci udad , Estado, y
C6digo Pos tal : A falta de estes datos, describa Ia localidad de su residen d a. (No lnduya el apartado de correos, cam ino rural, nl direcci6n comercial.)) (Dia chi w trU : Ten dub'ng va sO Phbng, Th<inh Phd, Tifu Bang, va M3 Bvu Oien.
Neu kh6ng co, xin dien ta nai quyvi w ngu (Khong dllc;tc de dja chi Hop Thll, Ilia Chi 1J11bng lang ho~ c Ilia Ch i Thllang Mail) lffif±lilihl : (:ij i!,lili!Jl:lll 01J '~H · m · tiHD~~* ~'l,~ • ~om ;_~# · iilli\"f WI OlllJilliHtlili~li ( ffi'l o/J IIl!ll~
/f;jf"8r5:; i~?~~t~i!.Brilil.il:
~')(
Mailing Address: City, State, and ZIP.
ail an not be delive red to your residence address . (Direcci6n postal:
Ciudad, Estado v COdigo Postal, si noes posible entregarle co rrespondencia en su domicllio). (Dia Chi Glri Thu:
Thil nh Ph0, Tieu Bang, vii Ma Bllu Oien. Neu kh6ng the chuyen thll t&i dja chi cu ngu cUa qw( vj .) mn~ ~f}( : iTi '
Hf!lJID~llll;]l;~R
(;.SOY CIUDADANOIA DE LOS
ESTADOS UN!DOS'!) (QUY VI
CO PHAI LA CON
-;.,N HOA
KY KHONG 'I) f
0
(Si)( Co )( ~ )
No
fNo)fKhong )('a )
TX Driver's licen se No. or Persona l I.D. No. (Issued by TX DPS) NUmero de
su licencia de conducir de Texas ode su cedula de ldentidad exp edida par
el Depanamento de Seguridad Publ ica de Texas). SO sang Liii Xe cUa tl ~ u
bang Texas ho ~ c sO 10 c:a nhan (do BO An roan Lao Of)ng tleu bang Texas
Date of Binh: Month, Day, Year (Fecha de
nacimiento: mes, dia, ano)(Ngily thcing nam sanh:
TMng, Ngay, Nlm) tiJ~I3WJ : FJ · 13 ·if:
.
I
Texas/Cedtila de identidad personal de Texas ni un Ntimero de
Segura Social.) ( T6i chlfa he dltqc cap b~ng lai xe cua Texas/so
ID ca nh a n ho~c so An Sinh Xa H('> L) ft))i_ ~ TX !'il:~UM\l51Ji:li!lll
@ .A.f;}Mm51Ji:li!ll~H ~'ti':i: ld1li!ll·
.. ' -
.
X
HomePCT
CERT/VUID
PCT
02/0
NUm. de Precinto·lugar de votaci6n/Phan Khu nai dii Bau Clt 56/in'QX!ti
1)}1, tJ!l\'ill!l!\5
(Mujcr)( Nil)(:!()
Social Security No. (last 4 dig its required tr you do not have a driver's license or I. D. number) NUmero de
Seguro Social. (Si no tiene lic:encia de conduc ir ni identificad6n personal, se requiere los Ultimos 4 nUmeros de
su seguro social) 56 An Sinh Xii HOi (4 s6 cuOi c:Ua s6 An Sinh Xii HOi c'an phiii c6 n€u quy vi kh6ng c6 s6 b3ng
l!i xe ho~c s61D c! nhan)
1HI'li' 1':l!~Jil!l (JI!l*ft: i!l. ~l'i!~fA~~@),. !i}fllO!!'i~li$ · ru'i tJEIJ\f±'li'fliJHJt
Date of Election Fecho de Ia ElecciOn
Ngay Bau eli ill$ 13 Wl
4
Male ~Female 0
fHombre )(Nnml(!I'J)
ARE YOU A UNITED
STATES CITIZEN?
100
Gend :(Optional) (Sexo (Optativo)) GJ&i tlnh :IK h6ng
blt buoc t£W ( UJl_l(~Of lJ'O
• Jl!l!l<'Eil'i!f!!l\itiiiili ft:rt-Jii!ii!JiliW: •
Check appropriate box.: Marque cl
cuadro opropiodo: Dlinh dAu vi10 6
thich hqp :ttiM'iii/Ji!lF'lllflltJ :
,
02/0-19
Voter Registrar U~ ONLY
PCT
Q;;;l. \ 0
NUm . de Preclnto-inscrito para votar/Phan Khu nai dii ghi danh s 6/ilf~
!Jiii)JI. :ltficll!l!l'i
FOR STATUS:
Type of Election n po de Elecci6n
Hlnh Thlic Bau e li ilH!Hli!ri
j'~~r-
BALLOT CODE:
1 q 2 Y 13 2 _!_ (j_ ~
(Write In the Batlot Code, it is found on the Provisional Batlot Stub above the
voter's signature area . The Provisiona l Ballot Stub is generated from the JBC.)
FOR VOTERS WHO OlD NOT PRESENT ACCEPTABLE PHOTO /DENT/FICA TION
1.
election day.
VOTER PRESENTED. A5fEPTABLE FORM OF IDENTIFICATION
~ES
L
ifNo
LF,;iod ' ' '"""' ""'"blo focm of idooUfi"Y'" oc ""' ,/,.,._
k"f p \ v-e__q
2.
3.
4.
5.
01/VY6() ~~"(
2.
. 3.
Voter executed religious objection affidavit within 6 days of election day .
4._/
5.~
6.
election.
7.
8.
9.
Information on file indicatina ooolicant comoleted a voter reaistration
Case 2:13-cv-00193
I~ 1JJJJJJ !!ill JllllliiJUililllllllllll
310904643
Declaraci6n Jurada de Votante Provisional I Ban Chlrr1g TM Cua Cu Tri T?m Thai I~~~~~~~~
TO HE CO,\II'LETEO BY VOTER: I am a registered voter of this politic<~ I subdiv ision and in the precinct in which I'm :mcmpting to vote and have not already voted in this election (either in person or by mail). lam a resident of
this politicnl subdivision, 1\;Jve not been finally convicted of a felony or if a felon, I have completed all of my punishment including any term ofincarc e r<~tioo, paro le, supc:rvision, pcriut.l of probation, or I have been pardoned. I hr.ve
not been dcu:nnincd by a finn I judgment of a court excrc isi.ng probate jurisdiction to be tot<JIIy mentally incapacitated or po.Htially mentally incapacitated without the right to vote. I understand th:Jt giving false information under oath
is a misdemeanor. and I understand that it is a felon y of the 2nd degree to vote in an elect ion for which I know I am not cligihlc.
(P ARA QUE EL VOTANTE LO LLENE: Estoy inscrito como vo tantc en est a s ubdivi.~i6n politic a ye n cl prceinto en eua l estoy intentando a vo tar y nun no he vo tado en est a elccciOn (en persona o por correo). Soy residcnte de
subdiv isiOn po litica. no he sitlo definit iva mente declarndo culpnb le de un de lito grove o si soy d aut or de un de lito grave, he cumplido toda mi condenn inc lusivc cl periodo de cncarcelnm iento , Ia libcnad condic ional. Ia libertnd
supen·isada. h.t libcnad vigilada. o he sido indultado. No me han dctcrrn inodo par un juicio final de una co ne de Ia lcgalizaci6n de un testamento, scr totalmemc incapacitado mcntalmemc o parcialmentc incapacitado sin cl dcrccho de
volar. F._~ticndo q~~ ~nr. inf~lrmflci?n fa I:-;~ .baj~ jura':lcn~o cs un d~lito '.nc~lOT y tambi~n c~ticndo qu: cs un d~lit?. gr.a~c ~e 2d~ gr~~o v?tar en u.n~ c_l:cci6n sabi~nd~ qu': n~ cu~pl~ c~n los.rcq~isit~; ncccsa~ios}: (D~'QC HOA~ TAT
B(H CU TRI: To1 In CLr IP chi gb1 danh bo ph1cu til• phan khu chmh tq d!a phliang n:::~y va Irang phan khu rna 101 co yd!nh b6 phu.:u va chua bo ph1cu trong cu<;>c bau cu nay (kc en d1ch than bo ph1cu hoy b6 ph1cu bOng thu). T01 cu
ngv .1\li p~iin khu chinh 1rj diu phtr(lng nby: t~i holm toiln kh6ng_bi k~llrQng t(li ho~c n~u hi nguUi p_h~m trQn~ tQi, tOi ~:3 ho:i.n th:i.nh .h~t mQi hin.h phQ.t, baa g6m IhOi hi,l~ tU,,:Jn trco, t.jU:i.n ch~. thcYi kY thlr t~:lch, hoQc d;J d~9'C tim_. P_~~n
quyCt cu6i cUng eUa tOa :in khOng tuyen bO rang t6i l:i nguOi m:it ho;..n to:ln nfing lvc vC m~t tOm thoin hay m:it mQt ph:in n5ng lvc dC t6i c6 quyCn duo-e b6 phifu. T6i hiCu r1!.ng khai man khi tuyCn th¢ sC b1 ph:,un khinh tQ1, vt.l 161 h1Cu
r~ng n[u b6 phitu trong m91 cu9c b~u cir ma uii biJtia minh khong h<)i du ditu ki~n.16i s~ bi coi Ia ph~m tr0ng 1(>i dr d(> 2.) EllUIR:Ililfl: :>$:.A.P\Jltif;'l:o5Wl1iF'lZ:g-;;t;jji[<!;. :>$:.A.~~:IIIiJ'ifl,j*l'fnt:;J;:illl!l'I'Hli'.'l (¥J!Ei!ll:ffill;:t
tQI'IiJ • ;f>A!)Jlt ilioMiimiZF.!i ~ · tt~dl31r!'l!i1fi!Jilimill:G;.~)£!JE · ~~~~~~m'l'l!f!go · l!!.f'Ji*JI:l!ii<J · 1!!12ilfii}l; · ll!l!:¥ ·li,'i'll\' · !llJ!Ul'JEJJ11't5ti!>!li:Eii2fli!R. • :>$:A.tt*illiJ:J'!IlliO[l!oi'ili!~~~'la:l£~*111$5t:'!o!l\:811fl1~
9<!;£;JJffiii!\\Hli',W~ • :4>:.A.RJllll!llLf.f1Ji!lilf!\1'1'J~~fll'lf.l!lm · .MzTWiiE"Jl~§ E:fftf;i'ijg((:J~JI.l'iEilll!l<PI'l~l'l=!ll!lilll1 •
es t::~
Middl e Name (if any) (Segundo nombre (si tiene)
last Name {Apellido) {HQI (!(!:)
en dem {neu c6)
9'rn9;j', ( 'iS''I'l)
ITencGI(~fn;j',)
LcuremL
Residence Address: Street Address and Apartment Number, City, State, and ZIP. If none, describe where you live {Do not inc lude PO Box, Rural Rt. or business address) (Domidl io: calle y nUmero de apartamento, Ciudad, Estado, Y
C6digo Postal: A falta de estes datos, describa Ia localidad de su residencia . (No induya el apartado de correos, camino rural, ni direcciOn comercial.)) (Oja chi cv trU: Ten dvCtng va s6 PhOng, Thanh Ph6, Tifu Bang, va Mii Bttu Oien.
""
:~·;-;,:;~ ~;;~~~;;;,;;;::'~""~"};;27~ ;';;·~"ln;j
m1F-""1;;;•.••,.•. ••••••«•• '~••
nacimiento: mes, dia, ai\o)(Ng3y thang n ~m sanh:
Thang, Ngay, Nlml t!J~ 81111 : J'l · 8 · ij:
Mailing Address: City, State, and ZIP. If mai l cannot be delivered to your reside e address. (Direcci6n postal:
Ciudad, Estado y COdigo Posta l, sino es posible entregarle correspondencia en su domicilio) . !Oia Chi Gtii Thv:
Th3nh Ph6, Tieu Bang, va Ma Bvu Oien. Neu kh6ng the chuyen thv tc:Yi dja chi cu ngv cUa quy vi.) Ii"U:tJ'f.tt!!.hl : ffi ·
il·llO!Iilli!!lllli~f!i
• ~D!If!!ll'i:fl!\\ii';i.liill!lf:e''@fj)IJ!hl: •
Mate D
{Hombrei{Nam)(!)l)
Check appropriate box: Marque el
cundro apropindo: Oimh dfi.u vilo 6
thich hqp l'fil'l'it;JH'JF'lllJll1:J ;
ARE YOU A UNITED
STATES CITIZEN?
(i,SOY CIUOADANO/A OE LOS
ESTADOS UN IDOS?) (QUY VI
PHAI LA CONG OAN HOA
c6
~es 'D
(Si)( Co)(ffi)
TX Driver's license No. or Personal I. D. No. {Issued by TX DPS) NUmero de
su licencia de conducir de Texas ode su cedula de ld entidad expedida par
el Departamento de Seguridad Publica de Texas). SO B~ng L31 Xe cUa tieu
bane Texas ho~c sO to ca nhan (do BQ An To3n lao OQng tieu bang Texas
.
I
FemateA6"
(Mujcr){ Nu)(P;)
Segura Social. (Sino tiene licencia de conducir ni ident ificaci6 n personal, se req ulere los Ultimos 4 nUmeros de
su seguro social) SO An Sinh X!i HOi (4 sO cu6i cUa sO An Sinh X!i HOi can phcii c6 neu quy vi kh6ng c6 sO b3ng
lai ••
hole solD ca nhan)
1±~'1<3':!111\illl
.
( ji[]Jl!!.Tol!'l'f.{\'t~~fA!f<l!l\:fljJ.A.§<IHO!I'IIi~~ · WIJiH!Hi'l<-!OQlJi
..
.
.-
No
{Noi{Khclngi{i§)
Segura s_ocial.) ( T~i c hv~ he ~vc;;_c ca:E bang lai xe cu~ Tex~s/si5
ID ca nhan ho~c so An Smh Xa H0 1.) 'I,X;;jt1'[ TX '(;);~'f\\tl,.~ili}E!i!!l/
f!e!.A.~M~il!JE!iJ!l'l'ZUit~ ~M!i!!l·
X
Date of Election Fecho de Ia ElecciOn
Ngly Bau Cil ill$ 8 Jill
Home PCT
Zc? 8
Per
PCT
020'6
NUm . de Precinto-lugar de votaciOn/Ph:iin Khu nai da B"au Clt SO/}g~f;Q
'l!i.lll:r.!Jtti!\1
CERT/VUID
7,."'"....,Q'-"",2f!{}.--
Precinct No. where registered _ _
NUm. de Precinto-inscrito para votar/Ph3n Khu nai d!i ghi danh s6/DJ:m;
!lli'lli JHi'.Jtt:M
Hinh Thl!c Bau Cl! ill!!l~~
FOR STATUS:
Authority Conducting Election Autoridod Administrondo lo Eleccidn
Crr Quon Th6m Quyen Ti€n Himh Bau Cv 3£f;ljJffif/11/ilf
the fo llo wing conc/usion(s) was made:
BALLOT CODE:
L :t_ ~ s ~
83 2
s
1.
election day.
VOTER PRESENTED ACCEPTABLE FOR~JF IDENTIFICATION
DYES
1.
cz0w
z.
3.
4.~ Voter executed natural disaster affidavit within 6 days of election day.
s._JL_
2.
3.
4.
5.
6.
election.
7.
8.
9.
Information on file indicatina ooo/icant comoleted a voter reaistrotion
.
.
1111111 1111111111 11111 11111 1111111111 111111111111111111
310909014
Declaraci6n Jurada de Votante Provisional I Bfm Chtmg Th~ Cua Cu Tri T:;l.m Thai I Wa~ili~§t~ ~
TO BE COM PLETE D BY VOTER: I am a reg istered voter of th is polit ical subd ivision and in the prec inct in which I'm an cmpting to vote and ha ve not already vo ted in th is elec tion (either in person or by mai l). I am a resident of
th is po litica l subdivisio n, ha ve not bee n fi nall y convic ted of a felo ny or i f a felon, I have comp lcted all of my pu nishment inch1d ing any term of incarceratio n, parole, supervision, period of probmion , or I have bee n pardoned. I have
not bee n determin ed by a final judgment of a court ex erc isin g probate jurisdiction to be rot ally ment all y incapacitat ed or partiall y ment all y incapacitated with out the ri ght to vote. I understand that gi ving fal se informal ion under ooth
is a misde meanor , and I un!..l crstand tha t it is i.l IC iony of the 2nd degree to vote in an election for which I know I um not eli gible.
(PARA QUE EL VOTANTE LO LLENE: Es10y insc rito como votante en cslil subd ivisiOn po litica yen cl pre cinto en coal cstoy intcntando a vo lar y aun no he vo todo en csta clecd6n (en persona o por corrco). Soy residente de
csta subd ivisiO n politica, no he s ido defin iti vomc ntc dcclarado culpa ble de un del ito grave o si soy c l autor llc un del ito gr<~ve, h1.: cump li du tolli.l mi co ndcna incl usive cl periodo de cncarcela micnt o, Ia libcnad co ndiciona l, Ia libcrtad
supcrvisuda , Ia libcrt <J d vig ili.Jda, o he sido indultado . No me han dct erm inado por un juicio fin <I I de una corte de Ia lcgaliza ciO n de un testamento , sc r tutalmcntc inca pac itado mc nt<lhnenle o parcialmcnt e inca pilci tado si n e\ dcrccho de
votnr. Enlicndo que dar informac i6n f::tl ~n b:1jo )uramento es un dcl ito mt: no r y tam bien ent ic ndo que cs un de lito ~=: rnvc de 2do grado vo tnr en unu c!ccci6 n sabicndu qut:: no curnplo con los n:quisitos ncct:surios. ) (OU'QC HOA~ TAT
801 C (f TRI : T6i hi eli tri d~ ghi donh b6 phiCu t\li ph:in khu chinh tri d in phLra ng n:'l y vil trong ph<in khu m~ t6i c6 y djnh b6 phi~u vii chua b6 phii:u trong cuQc b~ u eli n:l y (ki: c.:i dlch th5n b6 phi6u hay b6 phi~u bi\ ng th lt) . T61c\1
ng1,11 0i phtin khu chinh trj djn phucrng nity, t6i ho :in toiln kh6ng b j k~1 trQng tQi ho~c nfu hi nguOi ph1,1m trQnf t(l i, t6 i dil ho3.n tht.lnh hi:t mqi hinh ph~t. bno g6m thOi h\l n tU , a.n trco. qui n ch~. thO i k)r thU" thiJc h. ho ~c dil <luoc thu. Philn
quy~t cu6i cUng cUn tOa :in kh6ng tuyC n b6 rfi ng t6i 13 ngub"i m~t hoimtoi n nli ng lvc v~ m~l t:lm thAn hay milt mQt phft n nang lvc dt t6i c6 quy~n duqc b6 phiCu. TOi hii:u rdng khai man khi tuyCn th¢ sC bj philln khinh tQi. v:'l t6i hii:u
rfing n~u b6 ph ifu lrong m(>l cu(>c b~ u cu rna 16i bi~\ 13 minh khong hoi dil d i~u ki¢n, 16i sc bj coi 13 ph~m 1rong l(>i d p d(> 2.) F.llilH\:1:1;;);!: <l>:.ld'\Jlti&>5~!.11;1*1Z~>til! B1. <l>:.A.'i'i'!iill!ilifi.El<:ffitt'Xilllll<Plll:i'.'! (¥1!13;;,1.\ffiB*F
tll:i\¥) • ;4.:.A.li> Jlti&>Cit.l!E;Z@ ~ • ilN<f&1~'~lf!Nll ilii iiJiQ~J:E\'Il · !ilW~ I!I!·i:H~#lfH!l · i!l.l\'i#l!'.ii11 • §I'.Sti~ · 11.·lfl. • ~~ · illif'l ~ el~~>'Glfl ;;.\\E. Ifi;)J(!e • :4>:.A. 11*llliirl'l!illlOiill;EJi1:®~~'/i~Jt l!]fm$~~)llG~ I7l ¥~
:J<:IIEt.J i!iii!l\t.QlW!i! • :$.A. R.RHltlli:~11illiHJHfH"l<Rk>~mJ · :J!i TWI:ff"JI )ll @J c'Fff~i!Hll~ fli ;JtT-ifll.! !U<P ill: ;J.'U~.=:.tJHii:'" •
la st Name (Apellido) (Hoi (lit)
First Name (Nombre) (Ten) (;g)
Middle Name (if any) (Segundo nombre (si tiene )
en d~m (neu c6) <1'Fn9;g ( '~!ill" )
!Vttelvt i
(Ten cG) (tl lfl;g)
Re.sidence Address: Stree t Address and Apartment Number, City, State, and ZIP. If none, describe where you live (Do not include PO Box, Rural Rt. or business address) (Dom icllio: calle y nUmero de apartamento, Ciudad, Estado, y
C6d igo Po stal : A falta de estos datos , describa Ia localidad de su residenc ia. (No incluya el apanado de correos, camino rural, ni di recci6n comerciaL)) (Dja chi ell trU : Ten dltbng va sO PhOng, Thanh PhD, Tifu Bang, va Ma Bllu men .
Neu kho ng co , xl n di~n nai quy vi w ngv (Khong dvac di! dia chitA"Jw;. Oja Chi Ovi7"8 L~ng ho~c Oia Ch i Th~i)/'J;[f.J~t[ / tlj;g,J~~tlDZ>li!'l!l · iii · IHlU ~~.~ • !ll1J1!:;9.~ :_7rui11BJI @{±J~ ~ I i.llo/JffliMI
ta
l~m~MR@Hll9fiM..\!;g rm;;x~·,£l~]][ )~
lf 3t> UttGI Li r:;;:; l7j
I
Mailing Address : City, Sta te, and ZIP. If ma il cannot be de live red to your residence address. (Direcci6 n posta l:
Ciud ad, E.stado y C6digo Postal, si no es posib le entregarle correspond encia e n su domicilio). (Dja Chi Glri Thv:
Thanh Ph6, Tie'u Bang, va Ma Bvu Oi~n . Nfu kh6ng the chuyen thv t&i dja chi cv ng1,1 cUa qu y v].) !fil~~:fltlll: : Hi ·
HI«J ~~ ~i<J;~'I
tt-~
(] 6 n~/)( 77thy;
Gender: (Optiona l) (Se xo (Optativo)) Gi&i t fnh:(Kh6ng
bat buoc tt ~•J:
DJIJl;;J('FIJO
(
• ilD Jl![!(I~Ji\\;t.itil!J:D'l li5 1±11!;]][ •
Male 0
(Hombre)(Nam)(!/l)
Check appropria te box: Marque cl
cuadro apropiado: Dinh dfiu vi10 6
1hkh hqp :ffiillitt:tHIII*imlf ~J :
ARE YOU A UNfTED
STATES CITfZEN?
C6 PHA I LA C6NG DAN HOA
KY KH6NG '') !2J~l); li!l 0 Ei':'!1l?
'f;kes
(Si)( C6)(Jll:l
D
No
(No)(Kholng)('l§)
TX Driver's license No . or Personal LD . No. (Issued by TX OPS) NUmero de
su licencia de conducir de Texas ode su cedu la de ldentldad expedida par
el Departamento de Seguridad Publica de Texas). 56 B~ng Lcii Xe cUa ueu
.
Femal~
(Mujcr)( Nii) ( ~)
,,
...
..
Segura Social.) ( T6i chlfa he dlfO'C cap b~ng l:ii xe cua Texas/so
10 ca nhan ho~c so An Sinh xa Hoi.) r<;&~ TX ~!l'J:¥.1\!mSIJ!~/
(~A.~(]J~ !tJi~~t±~~~ \1}1 ~ •
Fl · El • iJO
Social Security No. (last 4 digits required if you do not have a driver's license or I. D. number) Nt.imero de
Segura Social. (Sino tiene llcencia de conducir ni identificaci6n persona l, se requiere los Ultimos 4 nUmeros de
su seguro social) 56 An Sinh xa HOi (4 sO cu6i cUa s:6 An Sinh xa HOi tan phai c6 neu quy vi kh6ng c6 s6 bang
-
[
X
Ngay aa u cv ill!!! El Wl
nacimiento: mes, dfa, aOoJ(Ngay thang n3m sanh:
Thong, Ngay, Nlm ) :±l ~ElWJ :
HomePCT
County Clerk Use ONl. Y
PCT
CERTNUID
Voter Registrar Use ONL. Y
PCT
cJ...Q'?
NUm. de Precinto·lugar de votaci6n/ Phfln Khu nO'i dii B'au Cti 50/ii~ ~
~.t Jll:i\¥~~
'-59---=
----'2;---"'.
NUm. de Precinto-l nscrito para votar/ Ph3n Khu nO'i d:i ghi danh s6/ ili ~
!l.iill!.
!J'i;[.~~
FOR STATUS:
Authority Conducting Election Auroridad Adminisrrando Ia Eleccidn
c Qu n
~6m Quy~ ~Hac;~;;
BALLOT CODE:
l ].3_ g_g_{_oCJG
voter's signature area. The Provisional Ballot Stub Is generated from the JBC.)
FOR VOTERS WHO D/0 NOT PRESENT ACCEPTABLE PHOTO /DENT/FICA TION
1.
election day.
DYES
~0
z.
3.
4.
5. ~ Voter did not satisfy identification or affidavit requirements, listed in
2.
Voter not on list of reg istered voters.
3.
4.
5.
6.
election . .
7.
8.
9.
Information on file indicating applicant completed a voter registration
PR
r - - - - - - -- - - - - - - - -- -
Case 2:13-cv-00193
310909032
Declaraci6n Jurada de Votante Provisional I Ban Chtmg Th~ Cua Cu Tri Tl;lm Thai I ~~il!~JUii1ilt
TO BL COM
VOTER: I am a regis tered votcrofthis political J
the precinct in' which I'm attempting to vote and ha ve not already vo ted in this elec tion (either in person or by mail). I am a resident of
this pol itica l subdiv ision, ha ve not been finally convicted of a felony or if a felo n, I have completed all of my punishment including any term of inca rccrution, parole. supervision, period of probation, or I have been pardoned. I hnve
nm been determ in ed by a final judgment of a coun exercising probate jurisdiction to be totally mentally incapac itated or part ially mentally incapac itated without the right to vote. I understand that giving fal se information und er oath
is a misdemeanor. and I understand that it is a ICiony of the 2nd degree to vote in an election for which I know I urn not elig ible.
(PARA QUE EL VOTANTE LO LLENE: Estoy in scri to como vutuntc en esta su lxJivisiOn po lit ic:a yen cl prccinto en cual cstoy intentando a votar y aun no he votado en esta elecc i6n (en persona o par correo). Soy rcsidcntc: de
subdivisiOn polilit:a, no he sido dcfinitivamcntc dcdamdo culpable de un ddito gr.1vc o si soy c l nutor de un deli to grave. he cumplido toda mi condcna inclusi ve cl period a de cncorcclamic:nto, Ia Iibert ad condicional, Ia libertad
supervisuda, Ia Iibert ad vigi lada, o ht: sido ind ult ado. No rue han dctcrminado par un ju icio fino:~ I de un a co rte de Ia legalizaciO n de un testamento, sc r totalmcntc inc apac itado merualmcnte o parcia lmcntc incapacitado si n cl dcrcc ho de
vo:a r. E.nticm.lo qu e dar inf?rmaci6n fa lsa biljO juramenta cs un delito r~enor y tambiCn enticndo que e~ un del ito grave de 2do gra~o vo tar en una d~cL·i6 n s:tbie nd~ que no c un~plo con los requisite~ necesnrios.)_ (E>~"()'C HOAN T ,\ T
801 CU' TRI: TO il~ clr tn dii ghi danh b6 phiCu ll;li phiin khu chinh tq d!a phuung n~ y vJ trong ph5 n khu mil tOi e6 'f djnh b6 phiCu vU chun b6 phiCu tro ng cuQe b5.u elr nily (kC eli dkh thUn bO ph1Cu hay b6 phiCu b~n~ tint) . T6i cu
ng1,1 t;.ti phiin khu eh inh trj din phvong nily. t6 i hoi111 to:ln kh6ng bi ktt trQng tc,) i ho~c n~u lb. ngu&i plwm lrQng tQi, tOi dil hoim thimh h~ t mQi hinh phvt. bno glun thOi hQn tU, lin treo, qu:in l:h~. thOi k)' thti ih6ch, ho~e dii thrQe tha . P~On
quy~t cu6i cUng eUa tOa :in kh6ng tuyCn b6 r~ng tOi lb. ngt~Oi mAt ho b.n tob.n n~ng lvc vt m~t t5m thAn hay m:lt mOt ph3n n:'ing lvc d~ t6i c6 quy~n du~;~e b6 phi Eu. T6i hi6u r~ng khai man khi tuyen t h~ sC bj phvm khinh tQi. vil t6i hiCu
r~ng niu b6 ph iiu trong on(>l cuo c bAu cu ma 1<ii bill Ia minh kh6ng ho) i du diiu kiin. 16i se bi co i Ia ph~m uvng IQi d p d(> 2.) lilil!~li'l !'i!: :<$:A.~iltiP.l:iMliliiF'lZiii;!;il!~. :.l>A'Iii:tlllliil.f;\l*tE!lt~il!!il'l'tll:l'il <mEiiit[~\lf
tll:Wil • 'l'A~~IltiP.l:>snrn;zm~ · !!t*ffllll=l'iffi~r,ifriiRlii~~l£>1\ . iit~llf'£fflm'l'lmm; · mffi~!!\;;J · §tl.i~ ;r; · ®fl ·
Wlf<J~ell!~7"t!f!.iite-~il}(~ • :<$:A.11t*·rl'iil:l !ll~iil!;;~;I!!Q~H'(l£fflffl1'i'7'i:1':iitffllf»~
~:sl<i
9dithi!illi\\1ll~I!Ii
mlr ·
• :.fi:AUJJII.!:TI'G'1£:~U\1-1'i~~R~f!Wll • :Mc"TiWt£BJl):UEIC.1-H'~~~M';tll;5Ll'l:Eil!ID<Ptll:i'll~=!:itmilll·
last Name
2
Name (if any) (Segundo nombre (si tiene)
First Name(Nombre) [Ten)
~Stc
demfneuc6)
Name (Nombre anterior)
cu)(mi!J :g)
Cii'=l'il
Residence Address: Street Ad dress and Apartment Number, City, State, and ZIP.If none, describe where you live {Do not includ e PO Box, Rural Rt. or business address) {Domici lio: calle y nUmero de apartamento, Ciudad, Estado, y
COdigo Postal: A falta de estes datos, describ;a Ia localidad de su residencia . {No incluya el apartado de correos, camino rural, ni di recc.iOn comercial. )) (Oia chi cv trU: Ten dub'ng va sO PhOng, Thanh Ph6, Tieu Bang, va Ma Bvu Oi~n .
~~~:~~;6·;n~~~~~~~:r~~~~~~~(/6"qjzi H(>J:iJC;;W~'vChiZfl/; ;;::;~;ytK;m:z;l:J~i#ffl~~
Mailing Address: City, State , and ZIP. If mail cannot be delivered to your residence address. (Direcci6n posta l:
Ciudad, Estad o y C6digo Postal, si noes posib le entregarle correspondencia e n su domicilio). (Oja Chi Glti Thlf:
Than h Ph6, neu Bang, va Mii Bllu men. Neu kh6ng the ch uy€n thlf t&i d ja chi Clf ng v cUa qu'(vj.) !('1\~!iliJll : rfj •
Gender: (Optional) (Sexo (Optat ive)) Gi&i tinh:(KhDng
bat bu(>c tt~IJ: ( DJIJ!i;jl;:ftil)
i·HfDif!F>i!Jlb'ili;JR • ~ffi[rf!'8'f!Jii;tu;i3\ !ir:if;J.@f11tlliJ!: •
cuadro apropindo: EM.nh dd u viio 0
1hich hqp t£ii1liit1J~F'lill'l1;) :
TX Driver's License No . or Personaii.D. No. (Issued by TX OPS) NUmero de
su licencia de conducir de Texas ode su Cedula de ldent idild e11pedida par
el Departamento de Segur idad Publica de Te )(as) . SO BAng l3i Xe cUa tieu
sO 10 c.a nhan
nacimiento: mes, dia, ano)(Ngay th3ng n.im sanh:
Thang, Ng~y. N~m)I.!Jg:13 JV!: FJ • 13 · ~
Male 0
Female~
(Hombre)(Nam)(Jij)
(Mujcr)( Nii)(fr;)
Social Security No. (las t 4 digits required if you do not have a driver's license or J.D .
Segura Social. (Sino tiene licen cia de conducir ni identificaci6n personal, se requ iere los Ultimos 4 nUmeros de
su seguro social) 56 An Sinh xa HOi (4 sO cu6i cUa sO An Sinh xa HOi dn ph3i c6 neu quy vi
lcli xe
sO 10 ca
ARE YOU A
STATES CITIZEN?
(LSOY CIUDADANO/A DE LOS
CO PHAI LA CONG DAN HOA
KY KHONG'!) !2!Jl::~i?.l~ll:;o,IJ; ?
~
0
No
(Si)( C6)(-Jl!)
NUm. de Precinto-l ugar de votaciOn/Phan Khu nai da sau
'l!!.tltl':iltllilti
NUm. de Precinto-inscrito para votar/ Phan
CERT/VU/0
~
PCT
Kh~h sO/iR~
FOR STATUS:
Ia E/ecciOn
BALLOT CODE:
l7 :J 8_ {)3_(2 ~6
Vater presented acceptable form of identification within 6 days of
l.
election day.
l:X-
DYES
~
2.
3.
4.
5.
i.
4.z
3.
5.
FOR VOTERS WHO VOTED PROV/5/0NALL Y FOR OTHER REASONS
6.
election.
7.
8.
9.
Information nn fil e indica tina nnnlir:nnt rnmniPtPrl n vntPr
rPni~:;trntinn
11111111111111111111111111111111 1111111111 1111111111111
310912509
Declaraci6n Jurada de Votante Provisional I Bim Chling Th~ Cua Cu Tri T<;1m Thai I I;~~~~~~
TO BE CO,tPLETED BY VOTER: I <1m a registered votcr oft his political subdivision and in the precinct in whic h I'm attemp ting to vote and have not a lready vo ted in this elec tion {either in person o r by mail). I am a resident of
this pol itica l subdiv isio n, hove not been lin ally conv icted of a felon y or if a fe lon, f have completed all of my punishme nt including any term of incarcera tion, parole, supervis ion, period of probat ion, or I have been pardoned. I h.a ve
not been determined by a final judgmt nt o f a coun exercising probate jurisd ict ion to be t01ally ment ally in capacitated or part ially menta lly incapacitated witho ut the right to vote. l understand tb:u giving false in for mmion under oa th
is a misdemea nor , and I understand that it is a felo ny of the 2nd degree to vote in an elect ion for which I know I am no t eligib le.
(PARA QUE EL VOTANTE LO LLENE: Estoy insc rito como votante en est:J subdivisiOn po litica yen el precinro en cuat estoy intenta ndo o votary aun no he votado en es ta elecc i6n (en person<! o por corrco). Soy reside nte de
esta subd ivisiOn politicn. no he sido dcfinitivamente dec/arado culpable de un dc lito grave o si soy cl autor de un ddito grave, he cumplido todil mi condcna inclusive cl pcriodo de enca rcelamicnto , la t iber t t~d condicional, Ia libertad
supcr\'isada , Ia libcnad vigi lada, o he sido indult!ldo . No me han dctcrm inado po r unju icio fin al de una co rt e de Ia legalizaci6 n de un testamento, scr tota lmcntc incapacitado mentalmente o pareialmente in eapac itado si n cl derecho de
vo tar. Entiendo que dar in formaciOn falsa bajo juramenta es un delito menor y tambi Cn cnticndo que cs un de lito gra.vc de 2d o gr:ldo votur en una clccci6 n sab icndo que no cumplo con los rcqu isitos ncccsa rios.) (OU.(.)C HOA.N T AT
B(J'I elf TRI : T6i lil cU tri eta ghi danh b6 phiCu t(l i ph!m khu chinh tr! dja phuong nily vil trong phOn khu mil tOi c6 )' djnh bO ph i ~u vi'! chua b6 phi6u trong cuQc biu ctr nily (k~ ca dic h th<in b6 phi~u hay b6 phi€u b~ng thu) . T6 i cu
ng1,1t<;li pht'ln khll chin h tri dja phuong miy, t6 i hofmtoim kh6ng b! k6t tn;mg tQi ho~c n~u hi nguO i ph¥m trong tQi, t6 i da hoan thanh h~t n'IQ i hinh ph (lt , bao g6rn thOi h;:~n tU, an trco, qu:in ch~, thCri k)• thti th:ich, ho~c da dLrQC tha. Ph:i n
q\ly~t cu6i cUng cUa tOa fm kh6ng tuyCn b6 ring t6i lit nguOi mch hoi\n toim nang h,rc vt m~t i.Jm thfm hay mAt mOt ph~n n3ng h,1c c16 t6i c6 quy~n duqc b6 phi~ u. T6i hi~u r;lng khai man khi tu yCn th~ se bi ph~m khinh tl)i, v;l t6i hi~u
ri ng nEu b6 ph i~u trong mQt cu(u.: b~u cl1 mi'l t6i bi~t la minh kh6ng hc)i dU di~ u ki~n. t6i sC b! coi lei ph¥111 trong t(>i dp d¢ 2.) Fhill!X.fJiR: ::.t;:.A.~tlti&~f5fa~r*JL:c§;5~;lig:, ~.A.¥Lt~U~ll~*tiJtt=Xi5!!iltfltli~ (f.J!§~liM"'t
l!l.~l • ~·.A.1'litl:iai5WR;L:f.!i~ · t'l';l<l2ilm:or!liJTHmlfii&~¥JE'lll · ~elli!l:ilH8~if!.g]l . ffiJ'fi1;fl!';.J · E!t.'i!l.i~ . 1m~· \lii'm' . tlllflll!oJEA~~'i'C!Il.~E.ll!i.lill'.. :<I'.A.t'l';t<l!li!1'!i!!;;i;Jl;tJMRm~JE imm~7'0~'l'i.1lllllt~
9dile:!Jifril!i\Jll:!/1!1£ • :<fi:.A.BJI!ll1i:C'1Jttili!FF11l!i'111'l~'Hil · ;ttc 7A!ft£AJlliDEIE'. 'Ft:firjl)'l~it:Jr.iill.Tf£illl!ll<t'l!l::!i11'l=~il!f!!ll' •
First Name (Nombre) (Ten)( ~)
last Name (ApellidoiiHo) (1/t)
Middle Name (if any) (Segundo nombre (s i tiene)
en dem Jneu col
opr.,,g, (:6'*l)
!Ten cu)
('i)AJ,g)
cuv-r
Residence Address: Str et Address and Apartment Number, City, State, and ZIP. If none, describe where you live (Do not include PO Box, Rural Rt. or bus iness address ) (Domicilio: calle y nUmero de apartamento, Ciudad, Est ado, y
C6digo Posta l: A fa lta de cstos datos, describa Ia localidad de su resi dencia . (No induya el apartado de correos, cam in o rura l, ni direcci6n comercial.)) (Oia chi cl.f trU : Ten dli'Ong va sO PhOng, Thil nh Ph O, Tie u Bang, va Ma Bllu Oien .
Neu kh6ng c6, xin di~n
FoiliHfl~R fi!'l
·
ta noi quy vi cu ngu jKhong dvc;tc de dia chi Hop Thv, Oia Chi Ovimg l !ng ho~c Oja Chi Thvong Mal)) J:l<LtJI!!!Jl :
l
lfi;j!,Ji!!!Jl:f01}!il~
· ill · Hif.!l[if,;lf"'~R • !IOJI:LJ!*l ·
·~~\"!mloJiflJllil<l1lt!!l\l
( :J'Jo/JIIll!ll
~BJII·lill'.~ ,gfillrltM ?Rtt!!t.il:
. If ma il cannot be del ivered to your res idence address . (DirecciOn postal:
Ciudad, Est ado y C6digo Po stal. si noes posi ble entregarle coirespondencia en su domk ilio). (Oja Ch i Glti Th v :
Th.lnh Ph0, Tteu Bang, va Ma Bvu men . Nfu kh6ng th f chuven thLf t6'i dia chi eLf ngv cUa quy vi.) !fiB~JIJ!hl_ : il) ·
HJfOlli~i!:'ii;ll;!fll
Gender: (Optiona {Sexo (Optati vo )) Gi6'i tinh :{Kt16ng
b~t buoc 11~'1 :
( CJl>i;;JG'flJO
Date of Birth: Month, Da y, Year (Fecha de
nacimiento: mes, dfa , ano)(Ng.ly th3ng nam sanh:
Thang, Ngay, Nlml tll!EBWl: J'l · 8 ·.If:
• !zli!R~W*i!liitllii'iHi!.:9~/i51ll~!Jl: •
Male D
Female
(Mujer)( Nfr)(:j{)
jHombre)JNaln)(!lj)
Check app ropriate box: Marq ue cl
cuadro aprop iado: E>iinh d.iu v;io 6
thich hc;tp ~Ii®'O\:JH~i*JIDIJi;):
ARE YOU A UNITED
STATES C!TlZEN?
(iS OY CIUD ADANO/A DE LOS
ESTADOS UNIDOS'!) (QliY V J
PHAI LA c6NG DAN HOA
KY KHONG'!) fi!.:Jll:ll:li!l1}fi!;P,~?
co
- ./ 0
~ es
(Si)( C6)(~)
N-"
0
INo)(Khong)li'l)
TX Driver's License No. or Personal LD . No. (Issued by TX DPS) NUmero de
su licencia de conducir de Texas ode su c edula de ldentidad expedida por
el Departamento de Seguridad Publica de Tex as) . SO B.l ng L;~ i Xe cUa tieu
bang Texas ho~c sO 10 c3 nhan (do BQ An Toan lao OQng th~u bang Texas
.
1
Segura Social.) I T6i chlla he dllc;tc dip bang lai xe cua Texas/so
ID ca nhan ho~c s6 An Sinh Xa Hili.) ttiil.'lif TX );\l~fiii?.\'PIJ!t!J!j/
i~J-.JH7Jili5fft!J!j!itf:l:tr'l?:i:ijjt!J!j •
Socia l Secu rity No . (last 4 d ig its required if you do not have a driver's licen se or 1.0. number) NUmero de
Segura Socia l. {Sino tiene licencia de conducir ni ident ificaciO n personal, se requie re los Ultimos 4 nUmcros de
su seguro social) SO An Sinh xa HQi (4 sO cu6i cUa sO An Sinh xa HOi dn phili c6 ne'u qu'( vj kh6ng c6 sO b.lng
lai xe ho~c so 10 ca nhan)
lHt'li'~!fllli"j
.
( ~O*f[:iJ!*l!li~~!&[email protected].!:tlil!ll!l!!li1'j • ~~!JiH~l±'lf·l< iillJt
·-
-
..
X
HomePCT
Per
CERT/VUID
Per
Date of Election Fecha de fa Elecci6n
Ngav Bau ell illli' S J!lj
NUm. de Preci nto-l ugar de votacl6n/Phim Khu nai da
B~ u
Clr S6/jjj[;r.;li
!l/l.l~l'.'!Jt!!i!l;
0
2: l{ f
NUm . de Prccint o- inscrito para votar/PhJ n Khu nO'i da gh i danh
!B)IIt.
sO/ill~
:i!:;i;~l'<\
Hinh Thl!c Bau c.:r il!IIHii~
CO' Quan Tht1m Quy€n
FOR STATUS:
nen HOnh BDu cti ~f.¥il!MI11Mf
-=;J&~tS {]xJ/1/'7
BALLOT CODE:
L tJ cJ
~ tJ
i- 0 7 ~
WHO DID NOT PRESENT ACCEPTABLE PHOTO /DENT/FICA TION
election day.
2.
3.
4.
Vater executed natural disaster affidavit within 6 days of election day.
!
0 YES
0 NO
1. /Failed to present acceptable form of identification or voter
5.
_L
2.
Voter .not on list of registered voters.
3.
4.
5.
cancelled mail bal lot application.
6.
election.
7.
8.
9.
1111111111111111111111111111111111111111111111111111111
310920509
Declaraci6n Jurada de Votante Provisional I Ban Chimg Th~ Cua Cu Tri T~m Thai I ~~ilU%~~:;:
TO BE C01\I PLETED BY VOTER: I am a regis tered voter of this pol itica l subdivisio n and in the prec inct in wh ich I' m a !tempting to vote ::md ha ve not nlrc:ady vo ted in this elec tio n (e ither in person o r by mail). I am n resident of
th is po litical sulx.livision, have not bee n finall y convic ted of o fd o ny or if a felon , I have comp le ted all of my punishment including any term of inca rceration, parole, superv ision, period of probJtion. or I ha ve been pardoned. I have
not been determined by a final judgment o f n court exc.:n:ising pro bah: ju risdict ion to be tot all y mc:ntally incapacitatt.:d or p:srtially me::ntall y incapacitated without the right to vote. I umkrstamlthat giving false informa tion under oath
is a misdemeanor. und I understand that it is u fe lony of the 2nd dt'b'TCC to vote in an election for which I know I am not eligible.
(P.-\RA QUE EL VOTANTE LO LLENE : Estoy inscrito como votantc en esta subdivisiOn rolitica yen el rrccimo en cual estoy.intentando a votur y nun no he vot:~do en es ta elecci6n (en persona o ror corrco). Soy rcs ident c de
est a subdivisiOn politica. no he sido dcfinit iva mente dcclarado culpable de un del ito grave o si soy cl au tor de un de lit o b'Tave. he cumplido tod:.1 mi co nd cna inc lu sive cl pcriodo de cnca rcelamicmo, la Iibert ad co ndicio n:.l\, 1:~ liberwd
supervisada. Ia libcrtad vig ilada, o he sido indultado. No me han dcterminado por un juic io final de un:.1 cone de Ia lcg:J.l izaci6 n de un testamento. ser t o t<~lmcnt c incapacitado mcntalmente o parcial mente incapacitado sin cl dcrecho de
vo!a r. E!Hicndo que dar informaciOn fal sa b::~jo juramenta cs un de lito mcnor y tambiCn cnticndo que cs un de lito grave de 2do gra?o votar en una cl~cci6n s abicnd~ que no eum,rlo con los rcquisito~ ncccsa rio s.) (ll~·oc HO AN TAT
801 CU' TR I: TOi Iii eli tri d3 ghi d<inh b6 phieu t~ i ph:ln khu chinh tri dja phucmg n:iy va trong ph:ln khu ma t6i c6 ydinh b6 phi Cu vii chua bO phi Cu trong cuQc b:iu cir n3y (k C d dlch th:in b6 phit!u hay b6 phi~u b~ng thu) . T6i w
ngl) t(li ph:ln khu chin h tri dja phuong miy, t6i hoii.n to:"m khnng hi k~ttrong t(li ho ~c nf:u l;) nguiTi phQm trc:mg t(li , tOi eta hn:in thilnh h~t m(li hinh ph;:at. baa g6m thOi h;tn tU, ian trco, quii.n ch~. thUi k}' thlr th:ich, hoi\c dO <.'h rQ"C thn. Ph~ n
quy~t cu6i cUng clw tOn Dn kh6ng tuyi!n b6 r~ng t6i l;i ngul'ri mfit ho:in totm n~ ng 1\TC v~ mQI t:im th~n hay mfit mOt ph 5n n!!ng hJCd~ tOi cO quy6n duQ'C bO phi~u. T6i hi~u r6ng khni mrm khi tu yCn th~ sC bi ph;_ull kh inh t¢i, vl1 t6i hi6u
rAng n~ u b6 phi~u trong m¢1 cu¢c b~u eli ma t6i bi ~t 1:1 minh kh6ng hQi UU di~u k i~ n . t6i si! bj coi 13 ph~m trQng tQi dp dQ 2.) ffillH\YJff~; Lj;::J,..~ttrniE+.'£[E;f)gZ.g.;tm~. *A 1:LW.mi.fifbj.5ktEJtt.=Xi5Jiflrpt.Q.WJ W[J3~!IH\~
Jll.l'i!) • ::4;:AJ:1> 1ltie< :sto~ .Zii!il': · t:t;r-~m'i'fiWJ!Jirillt<lllit:flt:W · li1Wil l!i!~m'i'flli::W · !!l.l'li:i'f!!\i'l · @t.S~Jf; · lliH~ · \lii'.il' · Wfflll<JEllt~'!CllH.l1Ei!\:~!e • :.t•At:t;f-fl>iD'Il!!.®i'.l!;tif!iilit:ftlilE~fl'/1'1'7t~:;J1ffi11illl'i
:'!<o'Et.lim!!iltl!:l'l!ll!. '~'A'JliP.1H:1'1Jtt!Ef!l:::rl'!nERl'lf.l!gJl. ill!T~HE'.Il~Eic::rr.tgn t:Hr:Jti!Nll.-r1'flll!ll'l'tl!:i'Rl'l=w.lliw •
last Name (Ape/lido) (Hal (!(E)
First Name (Nombre ) (Ten) (:.g)
Midd le Name (If any ) (Segundo nomb re (si tiene)
(Ten cu) CelillcJS)
en dem (neu c6) t/'Pa1:l". ( :t!i'l'l)
Residence Address: Street Address and Apartment Number, City, State, and ZlP. If none, describe where you live (Do not inc lude PO Box, Aural At. or business address) (Domidlio: catle y nUmero de apartamento, Ciudad, Estado, y
COdigo Postal : A ralta de estos datos , describa Ia localidad de su res idencia . (No incluya el apartado de correos, camino rural, ni direcdOn comercial.)) (Oia chi CU' trU: Ten dllb'ng va s6 PhOng, Thanh Ph6, Tie'u Bang, va Ma Bvu oien.
N€u kh6ng c6, xin di~n ta nai quy vi w ngv (Kh6ng dll<;tc de dla chi Hi)p Thll. Dia Chi !llllmg lang ho~c Dia Chi Thllang Mai)) @f:l)itl!l: : ilJol';l(ttJ['[tJ:l})ll'~,l · if> · i-/-/ftJ[<j:;:j'ffi;~,~ • !IJJJI',o.l!# · 5~ o'J'Wii!I.Fl'J@ f1lit!ll; ( Smo/JIIliD~
Rilll§'rMH!!!l • ~~~~I·I·IH.~iSi;l\li'Zilli~Jllili!Jl: l
Mailing Address: City, State, and ZIP . If mail cannot be delivered to your res idence address. (DirecciOn postal :
Ciudad, Estado y C6digo Postal, si no es posible entregarle correspondencia en su dom ici lio) . (Oja Chi Glti Thlf:
ThJnh Ph6, Tieu B.Jng, v3 M5 Bllu Oi~n . NCu kh6ng th<? chuyen thU' t&i dja chi cll ng1,1 ella quo,( vi.) ID~~jJ!fJ[ : ff] ·
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b~t
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( "flj'j,]i'Z'ft}l)
ji~IJ:
• ilrilll!lif.;tf!!\\i:i;itili![[:A~Ji!il:tlit!Jl: •
Male ..(5i.. Female D
(Hombre)(Nam)(]ll)
Check appropri.:uc box: Marque cl
cuadro npropiado : 0 6. nh diu vDo 6
thich hqp 1'fi®1l!Ji~i*lC!'J1;J :
Dale of Birth: Month, Day, Year (Fecha de
nacimiento: mes, dia, ai\o)(Ngay thcing nam sanh:
Thang, Ngay, N!m) W!E:EIWI: J;J · El · 4'
TX Driver's license No. or Personaii.D. No. (Issued by TX DPS) NUmero de
su licencia de conducir de Texas ode su CE!dula de ldentidad expedida par
el Departamento de Seguridad Publica de Texas). SO Blng L<li Xe cUa tie'u
bang Texas ho~c s6 tO ca nhan (do BQ An Toan lao OQng tieu bang Texas
(Mujcr)( Nii)(:9;)
Social Security No . (last 4 dig its required · if you do not have a drive r's license or 1.0 . number) NUmero de
Segura Social. (Sino tiene licenda de conducir ni identificaci6n personal, se requiere los Ultimos 4 nUmeros de
su seguro social) SO An Sinh xa HQi (4 sO cuOi cUa sO An Sinh xa HQl c3n phili c6 m!u qu'{ vj kh6ng cO sO b.\ng
Jai xe ho~c so ID ca nh!n)
1Ht'Si'3!'i!IU'!l ( !IOJI!!~;;j'i'fJ!l!!'.ftil!!(jJi'Zfl!lAffi}ffi~'illli!!i • ID1/h!IJH.±'Si'if@1Ji:
ARE YOU A UNITED
STATES CITIZEN?
(/,SO Y CIUDADANO/A DE LOS
ESTADOS UN /DOS?) (QUY VJ
kv KHONG') !-"':lil:~i!'!l01':0J5?
~Yes
D
(Sill C6)(:ffiJ
No
(No)(Kh6ng)(l§)
Texas/ Cedula de identidad personal de Texas ni un Ntimero de
Seg~ro Social.) ( T~i chtta he ~ttO:.~ caP. ~ng lai xe cua Tex:s/s6
JD ca nhan ho~c so An Sinh Xa H91.l 'J31;x:ij' TX '\1i:~¥J\!l\lii\'ili!!j/
f~.A.~f]:)Mf5t'tli!!j~t±~'R3til.t'Hi!!l
•
HomePCT
Per
County Clrrk Use ONLY
Ngay Bau Cit illl!lEI WI
O'Zh 5
NUm. de Preclmo-lugar de votaci6n/Phan Khu nai d.ii B"au Clt 56/lit~~
lt/r'/;;;-ot3
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!l!:\Wliti!\1
CERT/VUID
'255- I '0
Voter Registrar Use ONL 'I"
PCT
_Ot
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NUm . de Precinto-inscrito para votar/Ph3n Khu ncri d3 ghi danh
s6/j}j~
~'i/l.:lHclitl!li
Type of Elec tion Tipo de Efecci6n
Authority Conducting Election Autoridad Administrando Ia Elecci6n
Hinh Thtic Bau Cit il!l'!l~!!'l
Cd Quan Th6m Quyen Tiln Htinh BDu CV .:E.Mffif.i/11/ifJ
HrA rr~r;.
FOR STATUS:
C
BALLOT CODE:
voter's signature area. The Provisional Ba llot Stub is generated from the JBC.)
Voter presented acceptable farm af identification within 6 days of
l.
election day.
DYES
1.
D NO
~ailed to present acceptable form of identification or voter
2.
3.
4.
4. _ _
5.
Voting after
7:00P.M. due to court order.
7
Vater did not satisfy identification or affidavit requirements, listed in
6.
election.
Voter on list of peop le who voted early by mail, and voter has not
5.
2.
3.
7.
8.
9.
Information on file indica tina aoolicant com ole ted a voter reaistration
•
i •
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310928048
Declaraci6n Jurada de Votante Provisional I Bim Chfulg Th~ Cua Cu Tri T<;im Thai I W!Wi~iH~::~U~~
TO BE COMPLETED BY VOTER: I am a regis tered voter of this political subdivision and in the prec inct in which I'm attempting to vote and hove not already v01cd in this election (either in person or by mail). I am a resident of
this po litical subdivision, have not been finally convicted of a fe lony or if a felon, I have completed all of my punishment incl uding any term of incarceration, parole, supervision, period of probation, or I have been pardoned. I h:~vc
not been detcmlined by a final judgment of a court exe rcis ing probate jurisdiction to be totally mentally incapacitated or p3rtiall y mentally incapacit:ucd without the right to vote. I understand that giving false information under oath
is a misdemeanor, and !understand that it is a felony oft he 2nd degree to vote in an election for which I know I am not elig ible.
(PARA QUE EL VOTANTE LO LlENE: Estoy inscrito como votante en est OJ subdivisi6n politica yen el prccinto en cua l cstoy intcnt amlo a vo tur y uun no he vo t<Jdo en csla ek cc iOn (en persona o por corrco). Soy residcnte de
est a subdivisiOn politica, no he sido dcfinitivnmclllc dcclarado culpable de un dt:lito grnvc o si soy d autor de un de lito b'ravc, he cumplido toda mi condcn<J inclusive cl pcriodo de cncarcelamiento.la libcnad condicional,la t ib cr1<~d
supe n ·isad<l. Ia libcr1<1d vig ilada. o he sido indult::Hio. Nom~: han dct~:rminado por un juicio linul de una corte de Ia lcgalizaciOn de un testamento. scr lol.nlmcnt c incapacitado mcntalmcntc o parciahnente incapac itado si n c! dcrccho de
votar. Enticndo que dar inform1..1ciOn falsa bajo juramenta cs un de lito me nor y lilmbiCn cnticndo que cs un del ito grave de 2do grado vota r en una clccci6n sobicndo que no cumplo con los requisites nccc:;arios.) (OU'QC HOAN TAT
BOI eli' TRI: T6 i hi eli tri l.IJ ghi danh bO phiC:u l{li phlin khu chinh tri dja phuong: nilv va \rang phfin khu rna t6 i c6 y djnh b6 phi6u v:i chua bO phieu !rang cuOc bAu cti nily (ke cD dich thfin bO phi~u hay bO phi~u ~ng thLI). T6i Cli
ngl,l .t:J.i ph:i n khu ch!nh tr! dia rlmong nay, l~i hotm toiln khOng_ bj k6t trong tOi ho~c n6u l<l ngU'Oi P,hlllll I ron~ t(li. t6i ~a hofm thflnh. h6t mQi hin.h phQI , baa g6~ thOi hi,!~ tU., <in \reo, quim ch~. thiri k}' thir th:ich. ho~c d~ dLIQ'C tha. P~:l.n
quyCt cu6 i ctlng cUa t6a ~n kh6ng tuyC:n b6 n"mg t6i 1:'1 ngLIOi m5t hoiln toiln nilng h,rc v6 mJt uim thiin hay mfil mOt ph:ln nang: h,rc dC t6i c6 quyCn duqc b6 phiCu. T6i hiCu r:tng khai man khi tuyCn th¢ sC bi ph\).m kh inh t ~i, vii tOi hiCu
r~ng n~u !J<i phiiu trong m¢< cu1ic bt.u cu mo <6i bii< lo minh khong hoi du di~u ki¢n. <iii sc bi coi In ph1m trong <(>i dpdo 2.) Ellilt"'IJ'!i.i!: 4<A1Mt:i!ll:if5f;'ll]l;rAJZg;t;ll!~. ;J<A:(;j'~!lll.EI.fiil*:ffilt=,i;:ilH!l<Pil!:f,'i (1Jli3l£ill">f
fl!ll?l • ~'Ai-'ldtiliii5f.f;IJ1!:2:ml~ · i:E*F811~#ifi\'Eilill£iil"<i~JEjil · ';)'Wni:F.\i!m1'i!f!!JH · U11'1i'l'i'l~iin · §It~!\'~ · ffilff ·~'it · Wlflll~fE'.flgi:;'i')llll'ZE'.l!l~~ • :<!<.A.IIt;f.:*!Cl<!!lli<ilHit/E!IW!!.t)EI!JlJ'Il~;i;±:~~IJI\fllm
;HUJiffii!i\ll>.~.'l ftll • :>I'Af!il ~r.!][l'frlttMI!Fft7J!i<REirn:m · :lH il-r1fAJJ~~i3C.:fH3 'i!U:!A'!fi!l iRTfEill!ll •N9:Wil'! = t.&!f!!ll' •
Last Name (Ape llldo) (HO)
{~l:l
First Name (Nombre) {T€n) (;t~)
Middle Name (if any) (Segundo nombre (si tiene)
en dem (neu c6) '1'flijcg ( '15#)
(Tencu)(I':I J'fl~)
Residence Address: Street Address and Apartment Number, City, State, and ZtP. If none, des
where you live (Do not inc lude PO Box, Rural Rt. or business address) (Domicilio: cal le y nUmero de apartamento, Ciudad, Estado, y
C6digo Postal: A falta de estos datos, describa Ia localidad de su residencia . {No incluya el apartado de correos, camino rura l, ni direcci6n comercia l.j ) (Oia chi Cll trU: Ten dU'O'ng va sO Phbng, Thanh PhO, Tieu Bang, va Ma Bllu Olen.
Neu khong c6, xin dl~n <a nai quy vi w ngv (Khong dvqc de dja chi Hop Thv, flia Chi ovirng Lang hoac flia Chi Thvang Ma;J 1/i!l(tlit~f : lijcgJttlll:W0ll!~.~ · ifi · Jjjf{J!I!J;llflll;\W• !<O!l'!>i!:(;j' • ~~~~Wlt!iBJl@(£1~1!'1; ( :rlo/JRl[~\
Foll:1i~"-~6V;. l.'ll~fl{lt.Q~fill!l~itll~,~~~IJI:)
9lt \
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Mailing Address: City, State, and ZIP. If mail cannot be delivered to your residence address . {OirecciOn postal:
Ciudad, Estado y C6digo Postal, si no es posible entregarle correspondencia en su domicilio). (Oja Chi Glti Thu:
Th.ilnh Ph6, Tii!u Bang, va M3 SU'u Oien. Ne'u kh6ng thE! chuyE!n thu t6'i d ja chi CU' ngv ctia quYvi .) ~*it!!.t:Lt : if] ·
Gender: (Optional) (Sexo (Optative)) Gi6'i linh:{KhOng
bat bu oc ttfJ•J: <DJIJ{!X;FtJI)
~Female 0
HlfU!Ftli!Ril1M • j![J!f<!llF>~1ii\i;';il\l!!mB'JI§f:tll.tlll: •
Male
{Hombre)(Nam)(!f))
Check appropriate box: Marque el
euadro apropiado: Dilnh dAu vao 6
<hich hw:ffiri'lil:t:im rAJ CJIJi::J:
ARE YOU A UNITED
STATES CITIZEN?
z)
KY
(Si)( C6)(-Jl1:)
~~~~::,m?
(No)(Khong)(i§)
TX Driver's license No. or Persona II.D. No. {Issued by TX OPS) NUmero de
su licencia de conducir de Texas ode su C~dula de ldentldad expedida pa r
el Departa mento de Seguridad Publica de Texas). 56 B~ng Lai Xe ctia ueu
bang Texas ho~c sO ID ca nh~n (do BQ An Toan lao OQng tii~u bang Texas
.
I
(Mujcr)( Nfr)(:!()
Soc ial Security No. (last 4 digits required if you do not have a driver's license or I. D. number) NUmero de
Segura Social. {Sino tlene licencia de conducir ni identificaci6n persona l, se requiere los Ultimos 4 nUmeros de
su seguro social) 56 An Sinh Xii HQ i (4 sO cu6i cUa s6 An Sinh xa HQi dn ph31c6 n€u qu'f vi khOng c6 sO b~ng
Ill xe ho~c so ID ca nhan)
U~'li'~'iii!Jil.~ ( jlO!l(l.lJii!'&'l'li~ttl!!('!]j)i,fmA!JofJJlH~R!V; • li'tfltfl\ll:'li.'·I~Q~
.
'
' -
Segura Social.) ( Toi chU'a he dU'Q'c cap bang lai xe cua Texas/so
ID ca nhan ho~c s6 An Sinh X~ Hoi.) l'JWl.'i'J TX l'l%~<t1'Jl~St11li!'l/
(~.A.!t!Bffii!Jtli!'l~t± ~:tt~!i~li!'l •
Date of Election Fecho de Ia flecci6n
Ng!y Bau Cit illll!Bitll
nacimiento: mes, dia , aiio)(Ng3y thang nam sanh:
Thing, Ng!y, Nam) t!J!t8Wl : FJ • 8 ·ll'
HomePCT
County Cleric Use ONlY
PCT
CERT/VUID
Voter Registrar Use DNL Y
PCT
NUm . de Precinto-lugar de votaci6n/Phan Khu noi dii aau CV 56/ill!ni~
'ill!.ill:~llti!/i
NUm . de Precinto·inscrito para votar/Pha n Khu nol da ghl danh s6/ili~
!li~.
Type of Election npo de Elecci6n
H;nh Th<lc Bau c.r illl!ll:iil\'1
ftWl!!!\1
FOR STATUS:
Authority Conducting Election Aucoridod Administrondo Ia Efecci6n
CCT Quan ThDm Quyen
c:tM(
nen Himh BOu cv :EMiJJMUtiPI
~~$"
FOR VOTERS WHO DID NOT PRESENT ACCEPTABLE PHOTO /DENT/FICA T/ON.
voter's signature area. The Provisional Ba llot Stub is generated from the JBC.)
1.
election day.
DYES
1.
V
~NO
z.
3.
4. _ _
5.
,/Voter did not satisfy identification or affidavit requirements, listed in
Z.
3.
4.
5.
6.
election.
7.
8.
9.
. . _/~'l
CL£<-~
llllllllllllllllllllllllllllllllllll
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310930990
Declaracion Jurada de Votante Provisional/ Ban Ch1mg Th~ Cua Cu Tri T~m Thai /lm~ilt~~Ji!i:W
TO BE COMPLETED BY VOTER: lam a reg istered voter of this politica l subdivision and in the prec inct in which I'm allcmpting to vote and have not already voted in this elect ion (e ither in person or by ma il). I am a resident of
this pol iticill subdi vision, have no t been fina lly co nvic ted of a felony or if a fdon. I have completed all of my punishment including any term ofincarcenuion, parole, supervision, period of probation. or 1ha ve been p.:1rdo ncd. I have
nu t been detenn incd by a final judgment ofn court exerc is ing probate jurisdiction to be tota lly mema lly inc11pacilated or partiall y mentall y incapac ittued without the right to vote. I understand that giving fa lse in forma tio n under o!Uh
is a mi sdemc~mor, ond I understand thot it is a felony o rLhe 2nd degree to vote in on election fo r which I know I am not eligible.
(PARA QUE EL VOTANTE LO LLENE : Estoy inscrito como vota nte en esta sulxli visi6 n politi ca yen e l prccinto en cual estoy intentando a vo lar y aun no he vo tado en esta elecci6 n (en persona o por correo). Soy residc ntc de
csta subdivis i6n politica, no he sido defin itivamcnte deela ra do cu lpabl e de un del ito grave o si soy cl auto r de un de lito grave, he cumplido tod:l mi co nd cno. inclus ive cl pcriodo de cncarcclam icnto, Ia libertad condiciona l, Ia libertod
superv isnd n, Ia libcrtad vigilad n, o he sido indultado. No me hun dctcrminado por un juicio fin al de una co rt e de In lcg<Jlizilci6n de un tcstumcnto , ser totilhncntc incnrmc itado mcntalmentc o parcia !mente im:upncitudo sin cl derccho de
votn r. Enticndo que dnr informaciOn falsa bajo juramenta cs un delit o mc nor y tambien entiendo que cs un del ito grave de 2do grado vo lar en una clccc iOn s<.~bicm.Jo que no cumplo con los rcquisilos nccc sa rio s.) (DU'<;JC HOA.N TAT
BO I clr TR I: T{,j l;l clr tri d~ ghi danh bO phi~u IQi ph£ln khu chinh tri dja phucrng na.y va trong ph5n khu mil l{Ji cOy dinh bO phi~u vii ch ua bO ph itu !rung cu(lc b5u cti nily ( k~ d dkh than bO phi ~u hay bO ph i~u b~ng thu) . Tti i w
ngt,~lo,~i phUn khu chinh tri dj<J phuung n:iy, tOi huUn tuiln khOng bi k~t t r~mg t(li ho~c nCu Ja nguiJi phiJ.m trQn~ t¢i , t6i dil hoci n th;inh h~t mQi hinh ph~ t, baa g6m thOi h\HltU. iln trco. qu<in cht. thbi k)' thlt th<ich, ho~c dil duQc tha. Philn
qu y~t cu6i cUng elm tOa an kh6ng IU yCn b6 r~ng t6i I~ ngut'ri mjt hoan tofm n<l ng lt,1c v~ m~t tt.m thfin hay m~ t mOt ph~ n nan~; h.rc d~ t6i c6 quytn duqc b6 phi~u . TOi hitu dng khai man kh i tu yen thC sc bi philm kh inh t(li. v:l tOi hi~ u
rnng n~u b6 ph i~u trong mQ t cuQc b.1u eli m:i tili hi~t 1;', mi nh kh6ng h(li d\1 di~u kiCn, t6i si! bj coi 1:\ phQmtrong tQi dp dQ 2.) fBill~tJ{~: *A~Jltij(5f:if'B~r~zg;tiiH.'\:, *A~~fi'i.§_fbj*lfltt=Xllilnrttt!H.~ (f..RI3!N;ffijj~
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O!cti'Etlifiii!\IIQ;vi ll& • O!<.A.IJflll!E:'<ftli:llli!'<H!J'HRAfJ'1/ll · :.lliHn£11Jl1.!1Eic'fff~l!lli58'Jffl/;5l.TtEill lll•N'l: ;';i~= !ll!f!gf1·
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Firs! Name(Nombrc)(Ton) (.f,)
l ast Nam e (Apel!idol. (Hoi (lit)
• 'l•.A.f-£*1&u:l!ilto<f!;;t;IE~!HP:lEflilfl'll 1 1 1 iC~lll11liHlil'<
Midd le Name (if any) (Segundo nombre (si t iene)
(Ten cu) (\llfll.f,)
en dem (neu c6) 'i'ro9,g, ( ';f!;'l!f)
·' -~.
~(
Residence' Address: Street Add ress and Apartment Number, City, Sta te, and Z.IP. If none, describe where you live (Do not incl ude PO Box, Rural Rt. or bu si ne ss address) {Domici lio: call e y nUme ro de apartamento, Ciudad, Esta do, y
COdigo Postal: A falta de estes datos, describa Ia localidad de su reside ncia. (No incluya el apartado de correos, camino rur al, ni direcdO n comercial.)) (Oia chi cv trU : Ten dllimg va sO PhOng, Thanh Ph6, Ti ~u Bang, va M:! Bvu Oi~n .
Neu kh6ng c6, , ;n di~n 1a nai quy vi w ngv (Kh6ng dLtac de dia chi H~p Thlf, £lia Chi £lU'i1ng Lang hojc £lia Chi ThLtang Mail) /i51£JI!!JU: : fj'j,g,li!!JU::[U01./t~R · rtJ · iJi:[U[<fi~I]J;IJR • :(lOJl!;Ji*J · ~~j5~~·~R}'j@fl)l!!(!,l; ( ffi'Jo/JfH[<jl
J"jfg.ffi)l,~!!'} • ~191·~oi!i!,g,fiJlli'<:illil!'Ui!!IJJ:)
Mailing Address : City, State, and ZI P: If mail cannot be delivered to your residence address . (D ir'e cci6n pos tal:
Ciudad, Estado y C6digo Posla l, si no es pos ib le entregar.le correspondencia en su domicil io) . (Dja Chi Glri Thu:
Thanh Ph6, Tifu Bang, va M3 Buu Dien. Ne'u kh6ng the chuyen tht1 t6'i d ja chi cLJ ngv cUa qu'(vj.) mn~"'t iili±J.t : rfl •
jif!llilllli!Jl~Jl;l!l
Gender: (Optional) (Sexo (Op tative)) Gi&i tinh:(KhOng
b~! bu Oc f1~1J:
• idl!l!illll1<fi'\\;MHU::B'ilili111!!1JJ: •
( PJ!J!:;jli;'fi)O
Male~ Female 0
(H om bre)(Nam )(Jil)
Check appropriate box: Marque e l
cuadro apropiado: .E>:inh diu v:lo 6
thic h hQP :f£im'/1t:JJ!tll"ll[llf1:) :
ARE YOU A UNITED
STATES CITIZEN?
(.SOY CIUDADANO/A DE LO S
ESTADOS UN IDOS?) (QUY V!
c6 PHAI LA C6NG DAN HOA
KY KHONG?) i.l<il\!/<li!l0~D!!i?
•
.~DNa
(Si)(C6)(J]!)
(No)(Kh6ng)(l§)
TX Drive r's license No. or Person aii. O. No. {Issued by TX OPS) NUmero de
su licenda de conducir de Texas ode su cedula de ldentidad expedid a par
el Departamento de Segurid ad Publica de Texas) . SO s ang L.a i Xe cUa tieu
bang Texas ho~c sO 10 ca nhan (do 80 An Toan lao DQng th~u bang Texas
.
I
Te xas/Ced1lla de identidad personal de Te xas ni un Numero de
Segura Social.) I Toi chl.l'a he dl.l'<;tc cap b~ng lai xe cua Texas/so
ID ca nhan ho~c so An Sinh Xa Hoi.) 'l'Jtj~1J TX !ll:!l!f tl\P.~ldtb!!i/
@A.~ IBlli9!1n!!l~t±®'~:i:~b!!i"
NU mero de
Seguro Socia l. (Si no tiene lice ncia de conducir ni lde ntificaci6n pe rso nal, se req uie re los Ultimos 4 nUm eros de
su seguro social) s6 An Sinh xa HOi (4 sO cu6i cUa sO An Sinh xa HOi c'an phil! c6 neu quy vi kh6ng c6 s6 b$ng
xe ho~c s6 10 ca nh!n)
lai
.
.
.. .
'·
...
II
0
NUm. de Precinto·lugar de vot aci6n/P han Khu nai d3 B'a u Clr 50/m,[i!HW
IJR.Nl'/lli!!ll'i
PCT
County Clerlt Use ONLY
HomePCT
Precin ct No. where voted
-.
( idl!ii! !J:i~'l!fll!'l*~~.~li'Gif!I.A.ffitj]j!1!'lR!i!ll • iii'lllliM±'?i'-F~tli:
X
11-~-?-015
H8'?i'~'il11!i!ll
..
-
.
-
Date of Elect ion Fecha de lo Elecci6n
Ngay Bau ell U!l!l El WI
(Mujcr)( Nii)(:i>;)
Social Security No. (last 4 dig its requ ired if you do not have a driver's license or 1.0. number)
CERT/VUID
oL/-11-2(
41 {
NUm. de Preclnto-lnscrito pa ra votar/P han Kh u ncti
ocfI I
da ghi dan h sOjffiJ;g!
!®'l.t :l}iicltMI5
Type of Election Tipo de flecci6n
Authority Conducting Elect ion Aucoridod Adminisrrondo Ia f lecci6 n
Hlnh Thlic Bau Cit il!l!li!IH!'-!
Ca Quon Th6m Quyen Tiin HOnh BOu Cli .:J;~iJIN/11-MJ
PCT
FOR STATUS:
~o!lv/
(Write in the Ballot Code, it is found on the Provisional Ballot Stub above t he
voter's signature area. The Provis ional Ballot Stub Is generated from the JBc.)
l.
election day.
0 YES
1../
cert ificate wit h exemption .
z.
3.
4.--J
s.¥-
categories 1-4 above, within 6 days of election doy.
.2.
3.
4.
5.
Voter not on list of registe red voters .
6.
election.
Voter on list of people who voted ear ly by mail, and voter has not
7.
Vot in g after 7:00P.M. due to court order.
8.
9.
Information on file indicatina applicant completed a voter reaistrotion
---
\
llllllllllllll l lll310941504
lllllllllllllllllllllllllllllllllll
Declaracion Jurada de Votante Provisional I Ban Ch{rng TM Cua Ctr Tri Tc;tm Thai I ~~ilt~JUtf:f:
TO BE COt'\IPLETED BY VOTER: I :Jm a registered voter of this polit ica l subd ivisio n ;:md in the precinct in wh ich rm ancmpting to vote and have not already voted in this elec tion (either in person or by ma il). I am a re!'idenl of
this politica l subdiv isio n, have not been finally con victed of a felony or if a felon, I have comp leted all of my punishment including any term of incarceration, r:uole, supervision, period of probation, or I have been pardoned. I hilVC
not bee n dl:lcnnined by .. final judgment ofu co un c:xerc isi ng probate jurisd iction to be tolally mentally.incapacitatcd or partially mcmally incapacitated without the right to vme. I understand that giving false information under ooth
is a misdemea nor, and I unders tand that it is a felony of the 2nJ degree to vote in an t:lection for which I know I am not eligible.
(PA.RA QUE EL VOTANTE LO LLENE: Estoy inscr ito como votantc en esta subdiv isiOn politics yen cl preein to en cua l cstoy intentando a volar y aun no he vo tado en esto elecci6 n (en perso na o por corroo). Soy residenJe lit:
est a subdi\'i si6n polit ica. no he sido dcfinit iva ment e dccla rado cu lpab le de un de lito grave o si soy cl autor de un del ito gTilVC , he cump lido toda mi condena inclusive cl pcriodo de cncarcclamie nto, Ia libenad cond icio nal. !a lib ertad
supen·isada . \u Iibert ad vigilada, o he sido indultado. No me hi.!n dctcrm inado por un juicio ftnn! de una coned~.: lo lcgalizaciOn de un tcstnmcnto . ser totalmcnte inenpac itado mcntalmente o parcialmcnte incapaeitado sin cl dcrceho de
\'O_tur. E!lticndo que dar info rmaci6n falsa bajo jur:tmcnto es un de lito me nor y tambiCn ent icnJo que cs un deli to grnvc de 2do gra~o volar en una cl?cci6n sabic nd~ que no cumplo co n los rcquisitos ncccsarios.). (D~'QC HOAN TAT
8(11 C U. TR I: T6i hi clr tri dil ghi danh b6 rhiCu t" i ph5n khu chinh tri dja phuong n:ly va trong ph<in khu rna t6i c6 y djnh bO phiCu vU chua b6 phiCu trong cuQc bdu clr n:iy (k 6 c:i dic h thdn b6 phi~u hay bO phiCu bO.ng thu). TOi cu
ng\1 t;;ti phd n khu chin h tri dja phuang n<ly, t6 i ho~n to:in kh6 ng bj k6t trc;>ng t¢i ho~c n~u Iii nguiri pb;;tm trc;>np t¢ i. tOi d5 hoim th;lnh h~t mc;>i hinh ph<;~!, bao g6m thOi h<;~n tU , :in trco, qu:in ch~, thCri k:Y th Lr th<ich, hoOc d5 duoc thu . Ph:in
quytt cu6 i cUng cULl t O<:~ <i n kh6ng tuyCn b6 r~ng t6i l:i nguOi ml.t ho:l n toin n:lng ll,fc vC m~ttiim thfin hay miil mQt phAn nang h,rc d~ t6i cO quy~n dugc b6 phiCu. T6i hi ~ u r5ng khai man khi tuyen th¢ se bj ph"m kh inh tQ i, va tOi hi~ u
ni ng ntu b6 ph i~u trong rn¢1 cuOc b5u eli m.J t6i bi~tlil minh kh6 ng hQi dU d i~ u ki¢n, t6i se bj co i 13 ph;nn tn;mg t¢ i dp d¢ 2.) EBll!ect.A~: ~A~tlti13z)Sf.n~r>gz.g-;tiU]Bt ll~A~~mili~=*tiJit=)::llHflr?NW'- (il!3~ffill*
tit~)· ~'A.P\Jitil'.iXc;mll;2.1§1£ · i;'f;t,il.'ll8~llH1Hffiill:lht\~lUll · ~~~Pf9:!!!1li2~ID:!Ilt • illffr~!!liiil · jgt;5~lll: · II'J1'11 • ~1\l' · ~Jlli~Eif(~7t-W~E1l>ili!R. • >I'At'f*l&il'l'lll~f.lfEili®~~r~JErilli'll$7t~~llfllll~
~<ljg:JJiTiJ!ITWI:;;~UJi • >I<AfJI-JH17.:li!lii1Jtt!Jli!H!'I'l'l';RP\fl!;ll! · j(iTWHt'!i1iol@E'fB3i:!H8A'mi;5l.r:ffill!!l'l't.Q:l'.'ll\.=!ii!li'lll •
Former Name (Nombre ante ri or)
fTen cu) ( t1 Jtl:l!,)
Residence Address: Street Ad ss and Apartment Numbe r, City, State, and ZIP. If none , descri be where you live (Do not include PO Box, Aural Rt. or bu siness address) (Domicilio: calle y nUmero de apartamento, Ciudad, Estado, y
C6digo Postal: A falta de estos datos, describa Ia local idad de su residencia. (No incluya el apartado de correos, camino rural, ni direcci6n comercial.)) (Oia chi ell trU : Ten duOng va sO PhOng, Thanh Ph6, neu Bang, va Ma Buu Oien.
Neu khong c6, xin d i~ n ta nai quy vi w ngv (Kh6ng dvac M dja chi Hop Thv, Oia Chi ova
ffii fif.!il!t~fi!'i · :'ill1f~'Ji!~ !lr,r:~illi>tRlti!tJ!:)
ng
.
ho~c
O)a Chi Thvang Mai))Jl5(11ililll: :
tli~ljl;lll:fM}lll~JR
· m· iH11J[rJl1lH!lilli! • JnJ!lWH~ · ID'i'-f'.ai1JIAJ1Jl5(111i!il\l ( ID'lo/JIIl!l!ll
ailing Address: City, State, and ZIP. 1f mail cannot be delivered to your residence address. {Direcci6n postal :
Ciudad, Estado y C6digo Postal, si noes posible entregarle corresponden cia en su domicilio). (Oja Chi Glri Thll:
Th3nh Ph0, Tie'u Bang, va M.3 BU'u Dien. Neu khOng the chuyen thU' t&i dja chi ell' ngv cUa quy vj. ) ffi~i}fftt1Jl: : rJj ·
jH:fOl!~i!'lllli\tR
Thong, Ngay, N!mj W~. Bl1/l: 1'1 • 8 ·if-
• ~O!U~!!f!J\\;t<ili if !~e'~@f1Jilitll: •
~4Yle
Check appropri:lle bo:c Mo.rquc cl
cuadro apro piado: D:lnh d:iu v:io 6
th ich hap :ffiil!ill':JJKH''IID'ltl :
ARE YOU A UNITED
STATES CITIZEN?
(;,SOY CJUDADANO/A DE LOS
ESTADOS UNIDOS'?) (QUY VJ
c6 PHAJ LA c6NG DAN HOA
KY KHONG '!) !i!!Jl'd'<~0h~O!!l?
0
~5
,>-""' ' "
Date of Birth: Mont h, Day, Year (Fecha de
nacimiento: mes, dfa, ano)(Ngay th3ng n3 m san h:
(Si)( C6)~)
No
(No)(Khong)(i'i)
MaleD
fHombre)(Nam)(!J:l)
TX Driver's Ucense No. or Personal J. D. No. {Issued by TX DPS) NUmero de
su licenda de cond uclr de Texas ode su Cedula de ldentidad expedida por
el Depa rtamento de Seguridad Publica de Texas) . SO Blng Lci i Xe cUa tifu
bang Texas ho~c sO 10 ca nha n (do BQ An roan lao DQng tifu bang Texas
.
.
-
1
(Mujcr)( N ii)( ~)
Social Security No. {last 4 digits requ ired if you do not have a driver's licens e or J.D. number) NUm ero de
Segura Social. (Sino t lene licencia de conducir ni identificaci6n personal, se requ iere los Ultimos 4 nUmeros de
su seguro social) SO An Sinh xa HQi (4 sO cuOi cUa sO An Sinh xa HOi can phfll cO neu quy vi kh6ng c6 s6 b~ng
lai xe ho~c so ID ca nhan) 1if!'1<'1':'l!!!i'li ( ~O!lHT:i~~l!lMWI,.~~fl!lA!iti$l;J!;,R!l!l • ii'I!JtfJ\H'!i:-FIMit
·--.-
-
Texas/Cedu la de identidad personal de Texas ni un Numero de
Segura Socia l.) ( Toi ch11a he d11Q'c cay b~ng lai xe cua Texas/so
10 ca nhan ho~c so An Sinh Xii Hoi.) tJWFfif TX m~!J:fM~151f!fi!!li
(IMA.lil'i;J~~Rfi!!l~ti.1J'tt~IJJ16!!l
•
Date of Elect ion Fecha de Ia f/ecciDn
Ngay Bau Cl! ill!fl13ll/l
Femal~
Home PCT
PCT
PCT
Oob-g
552
NUm. de Precinto-lugar de votaci6 n/Phan Khu nO'i da aau Clt SO/.iligft-.lij
>:!'f. tll:i'lllti!!\1
CfRT/VUIO
Precinct No. where registered ---------,-~
NUm. de Precinto-i nscrito para votar/Ph5n Khu nai da ghi danh sO/}&~
ill>fil. :ll:oclti!ii\1
Autho rity Conducting Elect ion Auloridod Administrando fa flecci6n
Hlnh Thrrc Bau ell il!!fll!ll1l'i
Crt Quon Th6m Quyen Tien Hbnh Bau
FOR STATUS:
Cv .:E/ifff!i'lflitlil!
Gf!JJ[£AL.
I, the voter registror/deputy registrar, did research the records of my office ond
BALLOT CODE:
L Cf
22 0 2
'-fl. l
voter's signature area. The Provisiona l Ballot Stub is generated from t he JB(.)
1.
election day.
-
~
F•iled to
P"~"~~'~P"ble foc,t,:,~"loo
oc •otec
2.
3.
Voter executed religio11s objection affidavit within 6 days of election day.
4.
Voter executed naturol disaster affidavit within 6 days of election day.
s.Z
2.
3.
Voter not on list, registered in another precinct .
4.
5.
6.
election.
Voter o n list of people who voted early by mai l, and voter has not
cance ll ed mail ballot app lication .
7.
8.
9.
2:13-cv-00193 Document 737-5 Filed in TXSD on 11/17/14
rl -~ -llfllllllll~lllll.mCase
lllillrnlilil~lillllillll
- Affidavit of Provisional Voter
Page 58 of 83
310960001
Declaraci6n Jurada de Votante Provisional I Bim Chirng Th~ Cua Cu Tri T:;tm Thai I !m~Jlt~~*EB
TO BE CO;\IPLETEO BY VOTER: I am a registered voter of this political subdivision and in the precinct in which I' m ancmpting to vote and have not already voted in this election (either in person or hy mnil). I um a resident of
this political subdivision, have not been finally convicted of a felony or if a felon, I have completed all of my punishmcm including any term of incarceration, parole, supervision, period of probation, or I have been pardoned. I h<Jve
not bet::n determined by u final judgment of11 coun exercising probate jurisdict ion to be totally m~:ntally incapacitated or partially mcntillly incapacitatt::d without the rishtto vote. I understand that giving false information under oath
(rA.RA QUE EL VOTANTE LO LLENE: Estey inscrito como votantc en csta sulxlivisi6n politica· yen el precinto en eual estoy i.ntcmando a volar y aun no he votJdo en csta clecci6n (en persona o por corrl!o). Soy rcsidl!ntc de
est a subdivisiOn politica, no he sido de fin it ivilmcntc dccfamdo culpable de un de lito grave o si soy el au tor de un de lito grave, he cumplido toda mi condcna inclusive cl pcriodo de cnearcclamiento, Ia Iibert ad condic io nal, /;~ libcrtad
supcrvis11da. In libennd vigilada, o he sido indultado. No me han dctcrminado par un juicio fino! de una cor1c de Ia Jcgalizaci6n de un testamento. scr totalmcntc incnpncitado mcntulmcntc o pt~rcinlmcnt e incnpucitado sin cl derecho de
vo~<lr. E.~ticndo que dor int0rm<lci6 n f<llsn bujo juramenta es un de lito mcnor y tambiCn cntiendo que cs un del ito grave de 2do grn~o votor en una cl~cci6n sobicnd~ que no cu~plo co n los requisite~ ncccsarios.).(O~·Qc I-lOAN TAT
801 CU TRI: TOi Iii clr tri dii ghi d~mh b6 phiCu t{li philn khu chfnh 1rj dja phuang nily vit tron g ph3n khu m:lt6i c6 y djnh b6 phiCu v:l chua b6 phii:u trong cu(lc b5.u eli nily (kC c:i dich th5n b6 phiCu hay bO phiCu blmg thu). T6i cu
ngl,ll\li phlln khu chinh trj dja phuang oily, t6i ho:in !min kh6ng bi k~t trong tQi ho~c nCu 10 ngtti:ri ph\lm Iron~ tQi. t6i di ho:ln thimh h~t mQi hinh rh:;u, baa g6m thOi ~n tU , an trco, qu:in ch~. thOi kY thlt th:lch, ho~e d:l duqc tha. Phfm
quyCt cuOi cUng cUa tOa :in kh6ng tuyCn b~ ~ng tOi I;\ nguOi m~l ho:ln 10:\n n~ng hrc v~ m*t t:im th5n hay m5.t mQt ph5.n nang h,rc d6 t6i c6 quy~n duQc b6 phiCu. T6i hi~u dog khai man khi tuyt!n th~ s~ bj ph~m khinh tQi, vO t6i hiCu
ling nlu b6 phi~u <rong mQI cu(>c b5u cti mi1 1oi bi/11; minh khong h(ii du dilu ki¢n.1o i s< bi coi 13 phom lrQng 1(ii dp d¢ 2.) Ellill~lilK *.A1>iltiBU5~LllirAJz~;;l;ilJ~. :<t<.AfilUllll.r'l*l'filt'Xill!ll'l'lll:i':i (¥Jl13!i'i.!!lllif
llHI?> • *.A1>iltif:1;5f.'i~2~~ · I:N<f!illi!Nl!U!tililllli@~¥li!:" · !i'i.Oilf;HHIH!m~ · f§rfi:{;fl1JiioJ · §Jililliil\': · ll'.lll · \l.t'ID' • g)1J~J!<]E'.I!l~ll0l!l!i'i.ei!>il'<!e • :<I<.A~:t*·lllili:!IJ!l~i.!l;t!fffi<~~~li!:f!il*l'/1$'>\:~!i'i.ffi\flltl:t
!l<!iE:!JiliJI!\\tll:l\'lllll • :.j;:,ABJlD9.flfHt:tli!IJH'['.fl:'l'll\10!~Hi1 · :J1!71ill'fBJlWEie:ffof~l:'l'tlll01:111;)(l't£ill!il'l'll!~tl.:::. ~..!l.ffill¥. •
Llst
First Name (Nombrei(Tenl (:g)
Name (Apellido)(Ho) (!It)
Le_
Middle Name (If any) (Segundo nombre (si tiene)
en dem (neu co)
<Pr.,:g ('Iii# J
(Ten cO) (e!IIJ:g)
Residence Address: Street Address and Apartment Number, City, State. and ZIP. If none, describe where you live (Do not include PO Box, Rural Rt. or business address) (Dom icilio: calle y nUmero de apartamento, Ciudad, Estado, y
C6digo Pm;ta l: A falta de estos datos, describa Ia localidad de su residencia. (No incluya el apartado de correos, camino rural, ni direcci6n comercial.l) (Oja chi CU' trU : Ten dliCJng va sO PhOng, Thanh Ph6, Tieu Bang, va Ma Bltu Oien.
Neu khong co: xin dien ta nai quy vi w ngv (Khong dvcc di! dia chi Hop Thv, Oja Chi Dllimg U>ng hojc Dia Chi Thllctng M<i)) ~f1!Jtl.J!: : iljctJ1!!f.J!:;[{J0:m\1/i · ifi · jloffUijjfl~~llR • !lll!l!>.;J.# • ill'/O$WJ;)IBJlJi5(flt!ci!.l; ( lifo/.1/llffi~
fo; l1ljlf'5~~Mlctf~li'Zi!ll\tVI!ciJI:J
~ O
~
~
~.
If mail cannot be delivered to your residence address. (Direcci6n postal:
Ciudad, Esrado y C6digo Postal, si no es posible entregarle correspondencia en su domicilio). (Oia Chi Glti Thv:
Thanh Ph6, Ti~u Bang, vl Ma Bllu Dien. Neu khong the chuyen thll till dja chi Cl1 ngu cua quy vj.)
!E\l~lftlJI:
:
ifj ·
tfi:f1lffi~i!.!L]l;~·!lllll<!l!li*l!\\'tC~
MaleO
(Hombrei(Nam)(1)j)
Check approprialc box: Marque el
cuadro apropi::Jdo: Dimh d~u vao 6
lhich hqp l'f~~J:j~J'lll!IJ1:] :
ARE YOU A UNITED
STATES CITIZEN?
(iSOY CIUDAOANOIA DE LOS
ESTAOOS .UNIOOS'!) (QUY V!
c6 PHA I LA C6NG DAN HOA
0
(Si)( C6)(Jll)
No
(NoJIKh6ngJ1'6)
TX Driver's License
. or Personal J.D. No. (Issued by TX DPS) NUmero de
su licencia de conduclr de Texas ode su Cedula de ldentldad expedida par
el Departamento de Seguridad Publica de Texas). SO sang l3 1Xe cUa ti€u
bang Texas ho~c s6 10 ca nhan (do SO An Toiln lao fJQng tieu bang Texas
.
I
Texas/Cedula de identidad persona l de Texas ni un Numero de
Segura Social.) ( Toi chlfa he di!Q'c cap bang lai xe cua Texas/so
ID ca nhan hoijc s6 An Sinh Xa Hoi.) ']X;~'(ij' TX 1\\l~~il\~lll,'tli]!j/
@.A~i7Hl!)l'tli]!j!\JGH\1t'tf'i:SIR~ •
Ngay Bau Cit ill$ 8 Wl
(Mujer)( Nfr)(:ic)
Social Security No. (last 4 digits required if you do not have a driver's license or J.D . number) NUmero de
Segura Social. (Sino tiene licencia de conduclr ni ldentificaci6n personal, se requiere los Ultimos 4 nUmeros de
su seguro social) SO An Sinh xa HOi (4 sO cu6i cUa s6 An Sinh xa HOi din phfli cO neu qu'( vj kh6ng cO s6 bang
IOi ,. hoac so lDca nhan)
iHHi.'~'ll'!li!!l
( j[)*f.1::>5HLI\'I!I'itll!\\l!i'i.ll!l.AB}IJlffi'll'!li!!l ' mb\!I!HH<-F-Iiiilt:
-
.
.. .
X
Female
Home per
County Clerk Us~ ONlY
PCT
05
NUm . de Precinto·lugar de votaci6n/Ph§n Khu nai da sau Cli 50/iiHi§~
9,t
l.{t~ll!!i!.li
CERr/VUI()
0,5kL/
NUm. de Precinto·inscrito para votar/Ph<'i n Khu nai da ghl danh
!lii~.
PCT
sO/Ur~
!Hcll!!!'l;
Authority Conducting Election Au tor/dad Administrondo Ia Elecci6n
Hin~Cit
Ca Quon Thc1m Quyen
ill$1$l!l2
FOR STATUS:
nen HOnh Biiu Cti .EPfiJfibUIIPJ
!UT
e following conclusion(s) was made:
BALLOT CODE: ~~i_o.J ;<.O _f-fq{
1.
election doy.
1.
~to
~
0 YES
~?tved..
2.
3.
4.
5.
Voter met disability exemption within 6 days of e lection day.
3.
4.
f?«S5jltJY!J 5./
present acceptable form of identification or voter
certificate with exemption. [
~~
2.
.
6.
election.
cance ll ed mail ballot application.
7.
8.
9.
Information on file indicatina ooolicant comoleted a voter reoistrotion
: I·
'
1111111111111111111111111111111111111111111111111111111
310971507
Declaraci6n Jurada de Votante Provisional /B<'m Chtmg Th~ Cua Clr Tri T<;im Th<'ri I ~~~]E~~~~
T OllE ('0:\·li'LETE D BY VOT I~I~: I :1111
11
n:gis tcrr.rl vulcr u f this politica l sulxlivision anti in the precinct in which I'm nttcmpting to vote and have not already vo h:d in this elect ion (either in person o r by mail). I am u rc~idcnt of
1hi:; l~nlit i.:al suhdi\'ision. hn\'c no t hcl'tt linn lly conv icted nf a ICiony or if a fe lon, I have completed :.~II of my punishmcnt incl ud ing any term of incarceratio n, paro le, supervision, period of proba tion, or I have been p:mJoncd. I have
tl'.ll bc,:ll dl·tc rminc-d hy a fi n: tl judgment or :1 court c.xcrcising pro baiL' jurisdiction to be t o t :~ ll y mentall y inc:t pac it ntcd or pnn ia lly menta lly incnpncitatcc.l witho ut the right to vote. I understand that giving, fi1 lsc in formation tmdcr oat h
is :1 mistll.!llli.'OI!lOJ". and lumkrstand th;; t it i!: :1 fdm~y nf"tl •c 2ud Jcgrcc to vote in :lll elect ion for which I know J illll no t digiblc .
( 1 ' , \.:~J\ (li.JE
El.. VOTANTE LO LLENE : Estoy in:-;cr itn t·umo \'Otani!.! en c~ta sulxlivisiOn politic:J yen d prccinto en cuu l cstoy intcnwnc.lo a volar y aun no ht.: votado en csta dccciOn (en persona o por correo). Soy rcsideutc de
st•hd ivisi0n pn litiL"a. no hi.! sitl:1 ch:lini tiv:uncn tc lkcbrado rulpnb lc de on Uclito grave o si soy cl autor de on dclito grave. he compl ido toll<~ mi con<knu inclus ive cl pcriodo Uc cncarcclam icn to, Ia Iibe rt ad condieional, \a Iibert ali
:.•.qwt vi::ad:1. Ia lih~~rtad vigilnd;•, o he sic\tl indttlt;tdo. No mt: hu11 dctenninado por un juicio tin:~ ! de una co r1 c de Ia 1egalizac i6n de un testmncll to, scr tot;:llmc nte incapncitudo me nta Imente o parc ialmcntc im:a p:lcitado sin cl dcrecho de
\t~lnr. J:,\ti•:ndt1 qw~ dm inlill"lll:tl:it'l tl 1:11s:t h:~jt• iur!!mcnto ~): un Oclitn nH.:nnr y tamhiCn cnticnJo f.jUC cs 1111 deli! a grave Jc 2du gr:1do vo tarcn un:t ckt:ciOn ~:J bir:11do que nncumplo con los rcquis itns ncccsa rios.) {0 U"(1C IIOAN Tkr
11-:"H Ct"f TIU: Ttii l:i rtr tri d:i glli tl;lnh hti pldu t:_1i ph:in khu chinh tri difl phuong n;"ty v:'ltrong ph:i n ].;hu m:l Hii c6 y dit1h 00 phi~u v:'l clwa b6 ph i~u trong cuc)c btnt clr n:\y (k~ c:i dic h th:in bO phifu ht~y 00 phitu b.~ng 1htr). T6i w
11~:.1 1:_1i pl1:in ].;hu chinh tri Ilia phtmng n:iy, tUi hu:'ln toiln ].;hOng bj k~ t tro ng t(l i ho;)t: n~u l:i ngu(Ji ph~m trqng lf~i. t6i dil hoitn th6nh h~t mo i hinl1 ph:;a t. bno gbm thO i h<;~otU. :in trco, qu:in c h~. thtri kY thlr th:lch. ho~c da duqc tha. Ph<in
qu~-.it n••\i dmg ctw tr"1<1 ;iu kh1in3 tuyl:n hi-. nlng t6i lf!ng.uiri m:1t hofln to:'ln ni'lng l1rt: v~ m~tt ;imt h~n hny m;.\t m(lt ph5n n5 ng lvc.: d~ t6i c6 quy~n thrQ'C b6 phi~u. TOi hi~u r~ng kha i man khi tuyCn t h~ sC bi phiilll khinh t()i, v;t t6i h i~u
~~:ute n(·tt hi• nhifu t ron~ 111(1 1 t:H«)c h;\u .:l1 •u:"1 tt'•i hi~~~ 1:1 111inh khfu •g ht)i dU di~u ki~n. t6i sC h! coi l:i ph~mtrc;tng tt)i d,r dQ 2.) ftl fi1[\:lfi~: :4..::),J~d bf.!{;"f:it;t; ~r.tqL f~;t:~R . i.{,:A_:f4' ·.i!!WCLB.t"r'.15f~:(f!lt.=.Xil]Ulrl:~-t_a~:~ (f.~l§:lr£!11~~
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'ldi,'.}Jild.'!!\J'J:;'>\111 • ~' J,nJJII!.~n: : D'f~;: JmiJI:+fl'HOI\IM~iiTJI · ;IE) ' W(W~l:UEi cl'H'i;-H I3!1=J!J!lS1TIEUll.'l'i'I.Qi'U~=f1li[IUP. •
First Name (Notnbre) (Ten)
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(Ten cu) (ll\Jll~J
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c nc('. Add"~~s: St rc11t Adr:lrc$S il nd s\pi.lrtlllC111 Number, City, St.Jte, and ZIP. If none, descri be where you live (Do not include PO 80)( , Rural Rt. or busines s address) (Domici li o: calle y nUm ero de apartament o, Ciudad, Estado, y
f.•)dlen l,o )till: 1\ lall a de estes datm, Uo:o~clib;~ l .tloolidil d de su residcncia. (No incluya el aparta do de correos, camino rural, ni direcci6 n comercia l.)) (D ja chi cu tni: Ten d LI&ng va sO PhOng, Th3nh PhO, Tieu Bang, va Mii Blfu Di ~ n.
f-!,!u kh6n!1 c6, :cin dien t ~ nai qw( vi t: tr nc1.• (KhOn r, dlfqc d if dja chi HQp Tlut, Oja Chi Dv&ng LA ng ho~c Dja Chi Thlfang M ~i )) .lffi(t!~4f: : iJi:f;.!lt.i:ll::ftJ01j'91£ · i1i · ~{f.f.rJ!Ff. l*~~R • ~-!J!~~:(:I • M{~tff.:ITJ~IlJI.Ii!Hl~!r.\Jj ( ID'1o/Jfnmf\
J:<:. (:J~ i"i!PN ~~~~ • .ti.l;~J !·~·;~t~! :(;. frTi J;\~rrH ~t tttill: )
Ma il ing Add ress: City, State, and ZIP. If mail cannot be delivered to your residence add ress. (Direcci6n postal:
Ciudad, Es tado y C<Jdigo Pos tal, si no cs po:;ible cntregarle correspond encia en su domicili o). (Oja Ch i Gtii Thv:
Tha nh Phc5, Tieu Bil ng , va M5 Blfu Di('n. Neu khbng the chuyi!n thlf t&i d ja chi cv ng 1.,1 cU a qu'(vi.) !f~l!f.t~tJ[ : ffl ·
IH'f11 [;[:JI'I~jiR
Gender: (Optiona l) (Se)(O (Opt ativo)) Gi&i tlnh:(Kh6ng
bM buOc ['l')jiJ; ( nJ!Aii'Gl'lJO
Dat e of Birth : Mon th, Day, Yea r (Fecha de
nacimiento: mes, dia, ano)(Ngay th.ing n~ m san h:
Thang, Nga y, m m) te1:BHII: Fl · EJ · fJ'
• ljnJI!~1:ili'111\it ill ill!if;I1':J@ I'\'li!'.l.tl: •
Male;il
Female 0
(Hombre)(Nam)(Jil)
(Mujcr)( Nfr)(:i(:)
Social Sec urity No . (la st 4 digits requir ed if yo u do not have a drive r's lice nse o r I. D. numbe r) NUmero de
Se guro Socia l. (S ino tiene lice nd a de condu cir ni identlfic aci 6n pe rso nal, se requie re los Ultimos 4 nUmeros de
so seguro socia l) 56 An Sinh xa HOi (4 sO cu6i cUa sO An Sinh X,j HOi can phai c6 nfu quy vi kh6ng cO sO bang
:
A RE
YOU
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UN ITED
STAT ES CITI ZEN?
((.SOY CIUDADANQ/A DE LOS
ESTADOS UN IDOS'!) (QUY vj
CO l' II AI LA CONG DAN HOA
K Y KH6NG?) !~!f~:kl000 1:\;U,t!i?
D No
'171ves
,t.;:cc)(fi£)
(No)(t:hilng)(~J
0
: . • · • '• ·
I have not been issued a TX dri ver' s license/
Texas/Cedula de identidad perso na l de Te xas ni un Numero de
SogUI 0 Social. ) ( T6i chlfil he dlfQ'C cap bang lai xe cu a Te xas/so
ID ca nhan h o ~ c s6 An Sinh Xa H(ii. ) fti5H~· TX ~~~'IA~/il1Jlli]lj/
(~)._J!!-(75ili51'loll;~H~Y:~51111i!!)
Precinct No. w here voted
Home PCT
n
1· •
County Clerk Ust ONLY
PCT
PCT
osos
050!5
l!l:r.llt~l;
CERT/VUID
Precinct No . w here registe r ed
• • •· •
•
NUm . de Preci nlo·lugar de vo taci6 n/ Phan Kh u nai d3 B'a u CV S O/U!~fHi
'lilt.
-
X
TO BE COMP LETED BY THE ELECTION JUDG E
Date of Election Fecha de Ia E/e ccicin
Ngay Bliu Ctr il'i!ll13lYJ
. •· •• .
J.o0 J../
NUm . de Pre ci nto-inscri ta pa ra vot ar/P hi'in Khu nal da ghi da nh s6/iY(Ei
!f.'lR.
il'Oi':tlt~.i
FOR STA TUS:
Type of El eclion Tipo de Eleccidn
Hinh Thitc Bau Cli il'i!!l~~!!'l
BALLOT CO
A T THE POLLING PLACE
{Write in the Ballot Code, it is found on the Provisional Ballot Stub above t he
vote r's signature area . The Provisional Ballot St ub is generated f r om the JBc.)
1.
election day.
D YES
1. L
12{ NO
Failed t o present acceptable form of 1dent1fica tion or voter
2.
3.
4.
Voter executed natural disaster affidavit within 6 days of election da y.
5.
/
2.
Voter not on list of registered vot ers.
3.
Voter not on list, reg istered in another precinct.
4.
Vote r on list of peopl e who voted early by mail, and voter has not
cancell ed mail ballot application .
5.
6.
Not a registered voter or registration no t effective in time for this
election .
7.
B.
a
-- -- -------------------------------------Case 2:13-cv-00193 Document 737-5 Filed in TXSD on 11/17/14 Page 62 of 83
lllllllllll l lllll311014005
lllllllll lll lllllllllllllllllllllll
Declaraci6n Jurada de Votante Provisional I Bim Chlrl1g Th~ Cua Cu Tri T;;nn Thai I ifaB~i.H~~~rm attempting to vote and have not already voted in th is election (either in person or by m:ti l). I am :1 resident of
thi.~ ppl!tical subdi,·ision. h:1\'C not hcc n littal ly convicted nf<~ Jdony or if a !Cion, I h.,vc completed all of my punis hment includ ing o.ny term ofincarccm lion, pa role, ~upcrvision, per iod of probation, or I have been p::mloncd . I hnvc
n•.1 l be~~~~ dt•tc rm incd h.v 11 fina 1judg:mcnt n fa COllrt t•:.:c.rcisine proh:Hc juriscl iction to be tota ll y mcnt uJly incap:u.:itattd or r a rtia ll y men tally incapocit:Hcd without Ihe right to vole. I understand th:JL giving fa lse information under oath
i:' a mi~!lcm~..:a!tClr. :111d lumkrst;uld I hut it it> a ft:lony of the 2nd rJcgrcc to vote in :ln eh:ction for which I know I nm no t eligib le.
TOllE CO.\· IPLI~TEO H\' VOTE It: I nrn<.~ n.:gislcr~d vote r of this politicn l ~ubdiv isi n n und in the p rec inct in which
(1',\:'.,\ (_li.JE EL \'QT,\r"TE LO LLEi\E: btoy i11scritn como \'otnntc 1.:11 cst:l subdivisiOn politic.:a yen cl prccinto en cuill cstoy intcntando a vot:lr y aun no he v01ado en csta clccci6n (en persona o por corrco). Soy rcsirJcntc de
.:s1:1 snbdi\·isiOn pnlit i1.:01. no hc.: sitl:1 ddiniti vnmcn t(: dc.:c brado culpable de Ull dclito gnm.: o si soy cl aut or de un deli to grave, he cumplidu toda mi condcna inclusive cl periodo de cncarcclamicn to, In libcrtlld condiciomd, lu libcrtarJ
:.t:lwrvi:;:tda. Ia libntad vigilad:t, o ht~ si1 lt1 indulwdo . Ntl Jill.' lwn dc!cnninado pnr un juit: in fm:-tl rJc unu corte d1.· Ia h:gali7.nc.:i0n rJc un tcstumcnto, scr tota hncntc incapacitado mcntalmcntc o pan:ialmentc incapacit:1do si n cl dcrccho de
vot:tr. l·:nti•.:n1 ln l{lll: d:1r inli.trm:ll'ii•n li1 l.o:;u b;~jn im::mcnto es lm de l ito mcnor y Utmbit!n cnticndo qut: cs un de lito gr:wc de 2d u grado votnr en una cb:ci6 n sn bicndo que nu1.·umplo con los rcq uisitos ncccsa rio s.) (OU'QC I-lOAN TAT
iJ(.)I c't"f Til.(: '1'!1i l:l t'ir tri dil ghi !!:'lnh hO phif·u t;_ti ph:in kh u chinh tr! dja p!mong n;iy vit trnng ph:in kim m:i t6i cOy djnh 00 phi ~u v:'t chU'a bO phi~u trong Cll{lc hl.u ell n:iy (kC d dich thiin bO phi~u hay bO phil:u b&ng thll). Ttl i clr
~~~•.1 t :.Ji phfin 1\hucllinh 1rj <1ia plnrong n:"1y, tl1i ho:·mtoim khOng hi kC1 trQng tt,li ho~c nCu 1<1 ngliO"i ph;.m1 trQng tO i. t6 i dil ho<in th:'tnh h~tmoi hinh ph;:tt. baa g6 m thOi ho:m til. an trco. qulin clu~. th&i k)' thti thiich, ho~c dii rJuo-c tha. Pltl n
qu_v~;t ~.:u/1 i 1:i111g l't"t:l th:1 i111 1\hi,ng tll)'i.: u ht\ n1ng llii l:i ll~tn'ri m:\t ho{m toiu1 n~ng Jvc v~ m~t tcimth:~n huy m~ t m~i t ph::1n nilng lvc d~ t6i cO quy~n dug~.: b6 phi0u. l'i1i hi~u r~ng khai ma n khi tuyt:uth~ sl: bj ph:.tm khinh 1(1i, v;'t tbi hi~u
rimg n(·ulli.'• phi~·u tnnll; m(11 cu(ll' b~u cir m;', Hii bi(·t 1:\ mini! khtHl£ h(li dU di~~u k i~n.lOi si: b! coi l:i phi).m tr(l ug t(li c~p d9 2.) d3 lli l:'.:JJi,;L *Al.-:\llbeUkttr\llir~Lit;'tjjjR: , ~;.:).._:{q"~:~Jif. 1•j.5klfft:X.ffi~rj]1!HW (fJi§~!li):~
J'g'il · '4Illillif'I>Miii·!E2f.'ii!X · [,'J'"JW~fllli'11'Diiil~ii<~~li:mt · .XUIII'H/JBI'T![!$ · t!lr1i'l4 1!\oo · MI;~Ji!i · liN~ · \lii'llf · Wlf'II'JE'-ll!S\':5\:lfl!i'<Bltlill(!t • 4c.Ati'~<lt>il'i<Jiil~£l:!;tfii®trli~1i:fllM1>1>~3;Jil($MW
'UCIJilli.':~J'I.Wii~ · ~' I,IJ[O;tn::I'I';:JICII':nn'f;\Ht\!'Eln' · :·~'ili~lEnmuF-Jc'FH~W lon"JtiJ >JI."ftfiZ!ll'I'IQ:Wi~=~.!Hii!Jll •
L1 s1 Nnrnf' (1\p t~!lido) (HQ)
Utl:l
Middle Name {if anvJ (Segundo nombre (si tiene)
First Na me (Nombre) (Ten) (:ij)
en dem (neu col
q·•rm;g
<'Xii'H l
(Tencu)(f1/IH.i.J
!~ P.si ric.:n c(' Add tc.ss: Stree t .1\ddre:>s and /\p;utmr.nt Number, City, State, and ZIP. If none, describe where you live (Do not include PO Box, Ru ra l Rt. or business add ress) {Domicilio: calle y nUmero de apartamento, Ciudad, Esta do, y
r.'>dieo l)o:.tul: A (.JI Ia de cstos d.Jtos, r.l•:o:;criba b localirl <~ d dl'! su residencia. (No incluya el apartado de correos, cam ino rural, ni direcci6n comercial.)) (Oja chi ctt trU: Ten dl!Crng va sO Phbng, Th.lnh PhO, neu Bang, va MJ Bttu DiC:n.
N:!u fhoup, co, xin d i~n tl nai quy vi w nr.•! (Khonr. dli(Yc d€ dia chi Hop Thv, Dia Chi Dvang Lang ho~c Dia Chi Thvang Moil) @ltJI!!t!l: : l!i.i.Ji!!t!I::(U'<.}1U'lR · iii · iH:W~~~rn;'l,~ • !zOM!:)I# · oi/D\'!tlllOiiiJill§l11tl!lll; ( i.llo/Jffiif11
//.Jf2i1"j· j!,Vl,fill~
7 }_ 5*/;
· (c'ti"J'-. ~c1Ufta 1it
• ~(ll~'I·F;,;·~:~flf}T;!V,ff!i~Ri~lJ]:)
~
\\3
Mailing Address: City, State, and ZIP. If mail ca nnot be d livered to you r residence address. (DirecciOn postal:
Ciudad, Estado y C6diso Postal, si no es posib le c ntreg<:~rle correspondcncia en su domicil io). (Oia Chi Glri Th ll:
Th;\nh Ph6, Tieu Bang, va M5 Buu Oi~n . Neu kh6ng rhe chuyen lhtt tbi dja chi ell ngv cUa qu'( vj.) !J!fj=i~fJfuf.t.l: : rfj •
H-lfll'l![:l!R rn;;:,£ • !llln!'f'llW!f!Ui;iliill.'~:n~R!if1JI!!JJ!: •
nacimiento ; mes, dfa, ai\o)(Ngay th.1 ng nam sa nh;
Th ang, Ngay, Nam) t!J~:BIUI:
Male D
Fem ale ~-
(Hombre)(Nam)(Jij)
Ch~.:ck
nppropriatc box: Mnrquc cl
cuarJ ro apropiado: Oi1nh d&u vilo 6
th ich h<Jp
:{f ;N'i~')jf~l*ill/IJ~J
:
su llcencia de conducir de Texas ode su cedula de lde ntidad expedida por
e l Departam ento de Seguridad Publica de Texas). 56 B~ng Lilli Xe c:Ua tie u
:
ARE
YOU
i\
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:
R · 13 · ij:
(Mujcr)( Nil)(:!<:)
Social Security No. (last 4 dig its required if you do not have a driver's license or I. D. number) NUmero de
Seguro Social. (Sino tiene licencla de conducir ni identiflcaci6n personal, se requiere los t.ilt im os 4 nUmeros de
su seguro social) 56 An Sinh xa HQi (4 s6 cu6r cUa sO An Sinh xa HOi c'a n phai c6 n~u quy vi kh6ng c6 s6 bang
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UNITED
STATES CITIZEN?
(oSOY CllJDADANO/A DE LOS
ESTADOS UN IDOS'!) (QUi' V)
CO I'HA I LA CONG DAN HOA
KY K H6NG?) !,2! ·.le~~~.'~R:um?
mves
0
No
(No)(Kh6ng)(i§)
~ I have not been issued a TX drive r's license/
personal
identification
!
.
I
•
I
II
•
•
I'
'I
•
•
t
I
t .
t
)l 6
,
•
number or Seciai Seeo1 ity
~r. (No me han expedido una licencia de conduclr de
Texas7C edula de identidad personal de Texas ni un Numero de
Segura Social.) ( T6i chU'a he dU'O'C cap bang lai xe cua Te xas/so
10 ca nhan ho~c s6 An Sinh Xa Hc)i.) 'l:lWi'l'f TX !flllfW\~\HJ}1!i!!l/
(~.AJt (7}~1Ct!i!!l;j)Gf±~3<'3':lt}ib.l!j.
X
Home PCT
PCT
Date of Election Fe cha de Ia ElecciOn
Ngav sau Citii!lll13111J
0
NUm . de Precinto·lugar de vo taci6n/Phfm Khu n
'l!l.
tlU~Jful!l'i
CERr/VUia
Voter Registrar U.s e ONLY
PCT
Precinct No. where registered -~'1--'!.-+--
Nt.im . de Prec into·inscrito para votar/Phan Khu
tt.wc.
!HcJtMJ.5
FOR STATUS:
Authority Conducting Election Autar;dad Adm;n/strondo fa Elecci6n
CqQ)/;;:;;/~an{l;;:;tUIM!
I, the voter registrar/ deputy registrar, did research the records of my office ond
BALLOT CODE:
21 ~ l_ 9 1 ~5:_t(]
voter's signature area. The Provisional Ballot Stub is generated from the JBc.)
1.
election doy.
l._L
0 YES
~NO
Failed to prese nt acceptable form of identification or vote r
certificate w ith exemption.
2.
3.
Voter executed religious objection affidavit within 6 days of election doy.
4.--r
s._V_
Voter did not satisfy identification or affidavit requirements, fisted in
2.
3.
4.
5.
6.
election.
7.
8.
- - - - - - -- - -- - - - - -- - - -
311060008
Declaraci6n Jurada de Votante Provisional/ Bim Chtmg Th~ Cua Cu Tri T(:lm Thai I W/iB~iiH~~~~
TO 11E (Cr\H'LETED B\' VOTEH: I am :t n:gistcrl.!tl voter of this political ):ubdivi!-;ion and in the precinct in which I'm :111cmpting to vote and have not a l rc:.~dy voted in this election (eit her in person or by mail) . I am a resident of
this pn lit i1::1l subdivisio n, h:-. vc not hccn lina ll y ccm\' ictcd of a frlony or if a ll•lon. I ha ve completed all of rny punishment including any term of incarceration. parole , supervision. period of probation, or I huvc been pardoned. I h::I\'C
11 n1 h;:''ll tkll:rmincd h)' a tina I judgment of :1 cou11 c:~c rcismg probr~tc jurisdiction to be !Otnlly mentally incapacit<Jtci.l or par1ial1y men tally im:apacitated without the right to vote. I understand that giving false information under oath
is :1 m•-.d r.:lllc;lnnr, :mtl I understand th:1 t i! i!; :1 li:l;111y 11t'thc 2nd tk!?TCC to vote in 311 election for which I know /om not eligible.
(1' ,\t ),A (}UE El. VOTANTE 1.0 LLENE; baoy inscriJO como votJntc en cs ta Sl lh{livisi6n politica yen cl r rccinto cu cual c.~toy intcnt;mdo a volar y :am no he vot:u.lo en csta clccc i6n (en pcrson:l o ror corrcn). Soy rcsi dcn!c de
cst:J s••lxlivisilin pnlitit::l. no he sid~ dc!iaitivanh:ntc t.kdar:u.Jo rtllpnblc de un del ito gr:1vc o si :;oy cl autor de un de lito gmvc. he cumplido toda mi wm.kna inclusive cl pcriodo de cncarccl:unicntn, Ia Iibert at! condicional, Ia libcrtad
1:1 lihcrt;H[ vig ilad:1. o lu: sido induh:1dn. Nu mr.: han dctcrminado pnr un juicio lin a! de una corte de Ia lcga li za..:i6n de un testamento, scr totalmcntc incapacitado mcntalmcntc o parc ia lmcntc incarmcit<~do sin cl dcrccho de
, ..,~ar. E~~li• : ll([O 411c dar inftmnacit'tn fa \sa baju jun:mcmo cs un dclim mcmtr y tambiCn cnticndo que: es un dcli1o gr:wt.· de 2do j,!rado votJr en una cl~cci6n sabicnd~ que no CUfr!plo ron lo s n:quisiw~ nt:ccsarios.). (Dl!'O'C HOAN TAT
IJO'I CU TIU : Tt1i l:i dr tri d;lghi d:ltth bil phil~u t;,li pllfln khu chinh tr! d!a p!nrung n<'•y vittrong ph[m khu rna t6i r6 Ydjnh bO phi~u \'li rhu:.1 b6 phiCutrong r.:u(lc bftu clr nl•y(kt cil dlch thfin bU phiCu hay b6 phifu b~ng thu). T6 i r.:u
llG•.I.Ii)i pl.tfl n khu chinh trj dia plnwng n;iy~ ti~i ho:'mtutm kh6ng.bj klttrong tQi ho(u.: n~u lilngu6i P,h•:un lrQnp tQi. t6i ~il ho:l n tluinh,h~ t moi hin.h ph;,~t , b<tu giu.n th6i h\11! tU.Jmtrcu, quJn ch~. thOi kj tlni th:kh, hu~L' Ui'i Uuvc tha. Pl~;in
quy::=t l'U,·l ; t:i•ng l'tt;, \(\n D1 1 kh<ing tuyl:11 h<i riing t6i l.i ngui1i m;it ho~ n toUn n:ing lvc vC m~tt:imth :ln hay m;it m~t ph;jn n:ing lvc dC t6i cO quyCn duqc bO phiCu. TO i hifu rOng kh<li man khi tuyCn th¢ sC bj ph;;.m khinh tQi, d t6i hiCu
r:1ng n~11 ll(, phi~'lttrong m(J\ c11t)c hr1 u clr nui titi h i~·t Iii minh kh6ng h\li dU di0u ki~ n. tOi sC bj coi 15 ph<:'llllrQng t¢i dp J(l2 .) IJJ}g[1UJtS: 4:)d.~Uti&;f:it,1~f~Z~ ;r;m~. ~A~.Q~..fli1YJ5idfft:X.llHf19='f51~! (fJI.EJ])![~\~!f
I'll\'!)· <i'AliJitif.l:it.f.';l;if2Ji!iR · l:tiiJL~m:f•lnliliTITY\u'1<i1ltoe · Ji\:l11ll'l!l;'tm:M!f!lll' · lf!ffrfn!'ilol · t!J.I;~~U: · O:lf" · \lii'll!' · WlfiJ!'oJEIJi:'li:'i;;\f!.:<I(El!Hl(ie • :¥.A.I:t*N!<il:i~!tliillitflim%~)Efm>il'il'd;Ji\:ffi1Mili!
:J<fi,\:JJilli!!!\IIJ:I'Iilla • :<f'.A."Jlii~:O:r!:ilt:J!J!J':'Fltl'(;J l J.M'lHJl1 · .:tt7MifO!l}Jif;lcT-HitW!lln~t;!iill.T'ftill!fl •t•llti'libl =ttHfi'W •
~>l!pnvi:;;ula.
Lui NilfiH' (Ap1~llido) (HQ) (~'I;)
First Name (Nornbre) (Ti!n) (i;)
Middle Name (if a:ny) (Segundo nombre (s i tiene)
(Te n cu)(~~m:J:,)
enJ)' ('ii \l:l:, (~#J
nnsidcncc Adcircr.s: Street Address and Apartmc111 Number, City, StJte, and ZIP. If none , describe where you live (Do not include PO Box, Rural Rt. or business address) (Oomicilio: calle y nUmero de apartamento, Ciudad, Estado, y
f•)dieo Po')t~l : }\(aha de estes d.Jtos, describ;JI<JiocillidJd de su residencia. (No incluya el apartado de correos, camino rural, ni direcci6n comercial.)) (E>ia chi elf trU: Ten dvOng va sO PhOng, Th anh Ph6, Ti€u Bang, va M5 Blfu Oitn.
"''" 'ho11r, cci, xin di~n '" nui q11y vi w "C'! (Kh611n d~uc de dia chi H¢p Th~. Oia Chi D~img Lang ho~c Oia Chi Thuang M~i)) /ffii±l~hl : !fj~l~l:il:fll0li!liil · iii · j@J~1111HlHJ1 • ~n!l!iJH-f · m'iii'fWI~'l'l@(1J~11\ ( Wo/JRl[~
J,;J~:]lnj3~;~?fl:f'::A ~ ~
fl3 16
Mailing Address: City, State, and ZIP. If mail cannot be delive red to your residence address. (Direcci6n postal:
Ciudad , Estado y C6digo Postal, si no es po:;ible cntregarle correspondencia en su domkil io). (Oja Chi Glti Thll:
Th3nh PhO, Ti eu Bane, v3 Ma Bllu Dien. N€u kh<lng the chuye'n thll t61 dja chi cll ngy cUa quy vj.) [rU~tl!;.I[ : iiJ ·
Gender: (Optional) (Sexo (Optative)) Gi&i tinh:(Kh6ng
b~ t bu(>c ti~tl: ( O]'lj{Jji!::[C!J()
!HfHIDJ:J!ilm;\IN • <m~mmcm,;t;illi£!il':li'J®!1J~JJI: •
Male D
Female
(Hombre)(Nam)(]ll)
cuadro apropiallo: O:inh U~u v:'lO 0
<hlch hvr :(Ei§1i~1j!SI*lffillt:J :
ARE YOU A UNITED
STATES CITIZEN?
ESTIIDOS UNIDOS'I) (QUY V)
CO I'IIAI LA CONG DAN HOII
Ki'2:)U~::~?
(No)(Kh6ng)(i§)
(Sil( C6)(:lJ.':)
TX Driver's license No. or Persona II.D. No. {Issued by TX DPS) NUmero de
su licencia de conduc:ir de Texas a de su cedula de ldentidad expedida par
el Departamento de Seguridad Publica de Texas). SO sang l<ii Xe cUa tieu
.
I
Texas/Cedilla de identidad personal de Texas ni un Numero de
Segura Social.) ( Toi ch11a he di!Q"C cap b~ng lai xe cua Texas/s6
10 ca nhan ho~c s6 An Sinh Xa Hqi.) ~i§!:(;j' TX ~ll£tl\P.~l1!1!i)Jj/
. .
...
. .. .
. .. .
,. .. '.
'
X
Home PIT
.Precinct No. where voted
()
CERT/VUID
'/..__,t"-_/__,. ,.
~5\
Precinct No. where registered _ _
NUm. de Precfnto-inscrito para votar/Philn Khu nai da ghi danh s6/iiiW!
!j;i'l!/.!HC,Iilil!\5
PCT
IJ
NUm. de Precinto-lugar de votacl6n/Ph:in Khu noi da B'au Cti SO/llii~Ji
'l!i. tlH'i.!Jilil!\5
,
.
o
Hlnh Thlfc Bau C.! ill!Jl::/i!\!1
(Mujcr)( Nil)(:ic)
Segura Social. (Sino tiene lice ncia de conducir nl identificaci6n personal, se requiere los Ultimos 4 nUmeros de
su seguro social) SO An Sinh xa HQi (4 sO cuOi cUa s6 An Sinh xa HOi c:~n phai c6 m1u quy vj kh6ng c6 sO bc\ng
tl
lf.ll.A.JltllHlt. ~H!i)Jj~iUi''if:i:~RK'.!l
Ngay eau cuill!!< El Wl
nacimiento: mes, dfa, aiio)(Ngay th3ng nam sanh:
Thane, Ngay, Nam) t!H:BJPI: !'l · 8 · i:jc
PCT
0
'lO
(Q(
FOR STATUS:
I, the voter registrar/deputy registrar, did research the records of my office ond
Authority Conducting Election Autoridad Adminlstrando Ia ElecciOn
CO' Quan Thom Qu en Tien Hlmh Bau Cti' .1;/ififfflfttf/,Jf
~
BALLOT CODE: :Z..j_ J.o(_!>-7 'I 0 I 9
(Write in the Ballot Code, it is found on the Provisional Ba llot Stub above the
AT THE POLLING PlACE
Voter presented acceptable form af identification within 6 days of
1.
election day.
0 YES
OJ1<fo
2.
3.
Voter executed religious objection affidavit within 6 days af election day.
4.
~/ S
2.
3.
4.
5.
/1j.J3
5.
/
6.
election.
7.
8.
9.
lnfnrmntinn nn
fifp
inrlirntinn nnnlirn nt rrlmnl~>torl rr untor ronictrnti"'"
-- I
I
IIIIIIIJijJJIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
311060026
Declaraci6n Jurada de Votante Provisional I Ban Chtmg TM Cua Cu Tri T?m Thai I !mB~ill~~~~
T() n 1: ('( >.\ Ir t.E'J'f.l) II\' VOTEH: I asn a r~.:gis t crct l voter of this politicul subd ivision and in the prec inct in wh ich I'm :~ucmp t ing to vote <Jnd have not a l rc<~dy voted in this election (e ither in person or by mn il ). I 11m a resident of
thi.~ pol it i~::d :-: nhJ i'•ision, ha ve. not hcc •t fin:1lly muvictt•d of :1 felon y or if :1 Cdnn, I have complch:d all of IllY punishment iw.:luding any tcnn of incarccrat ion, parole, supervision, period of prob;"~tion, or I ha ve been pnn..loncd. I h:~ vc
not hci:H dt·u:nn incd hy a final judg.mt·nt of a cn t1 11 cxcn.:is111g prnbntc jmisdkt ion to be to1:1Jiy mentally im:<~ pa c ita t cd or partiall y mentally incapacit<:llctl withou t the righltn vote. I understand Ihat gi ving !Uisc information untlcr oat h
i.~ n rnts<lcmca!tor, ;1od lum.h:rst;md tlmt it i:; a f<:/ony o ft he 2nd degree to vote in <ln election !Or which I kno w I am not eligib le.
( I',\. H.1\ <..HJE El. VOT,\l\'TE 1..0 LLEN E: Estoy iuscrito como \'O tant c en csta subd iv isiOn pol iticn yen cl prccimo en cual cstoy int cmando a votary aun no he vmado en csta clecc i6n (en pcrson<1 o por correo). Soy rcsidcnt e de
t:s t:1 Sllhdi,·isitlll politicn. ntl he sid~ th.:linitivumr.:ntc clccbmclo culpab le dt: un de lito grove o si soy el outo r de un del ito grave. he cumplidn tudo mi comlctlU inclusi ve cl pcriodo de enca rcclamicnto, la Iibertad comJiciona l, Ia libcrtad
:;up~·~ vi:;:1d:1. l;t Jihcrtnd vig il;1da. n he sido indu!rndo . No rm.: Jwn dctc nninmlo por 1111 juicin lin:d de una cnrtl! de l:l lcg;~ l iz;Jc i 6 n de un tcst;uncnto, scr totnlmcntc inc:l p:lcitndo mentalmcntc o parci:l lmentc in cnra cit:tdo sin cl dcrccho de
\"O~ar. J:~~~i~~wln qlll; d<1r inlill"lnae i(m fillsa lm.io )uramcnto l:s un l..lclito mc nor y lllmbiCn cnticndo que cs un tic lito gmvc de 2do gra~o vot <~ r en unn cl~·cci,)n sn biL' nd~ que no cun!r lo con los rcqu is ito~ ncccsurios.)_(Ol/Q'C IIOAN TAT
IJ()"I C l f Til. I: Tc", i I~ ct"r tri doi ghi d<"lnh hO phil~u t;_
ti rl1:i u l.; hu ch inh trj Jja rhuang nl1y vii. trong ph{ln khu m:i t6i c6 -jdj nh bO phiC u vO chuu bO phiCu trong ct1¢c b.iu eli nity (kC d dich thii n bO p h i~u huy bO phiCu b~ng thu). T6 i w
HJ..:\1 tt;~i ph:l n ~ 1m chinh trj ilia plllrrmu n:'ly, ttli hu:'ln to:l n kh6 ng bi kCt tr(lng tt)i ho~c n6 u Iii nguc'ri phym trQng t{l i. tO i dil ho:"m lh3nh hCt moi hinh ph~t. h:..to ghm thfri h:;w tU, :in trco, qu:in cht, thOi kY thlr th:kh. ho(lc dil duvc tha. Ph:in
quy~ t cw\i ciutJ; t:\):1 t:Ja :·m khOn:; lny<':n hA rfmG tOi l;l n:;tr(Ti tn:1t hoft n to:i n n~ng lvc vC m~tt:i m thA n huy m;i t mQt ph:1n n:1ng lvc d~ t6 i cO quy~n duQ'c bO phi~u. T6i hi6u n1ng kha i nKitl khi tuyfn th¢ sC hj ph~tm kh inh tQi, , ,:j t6i hi~u
rlu1g n~·~~ hit phiCu trong tnt) I cw:1c b:iu clr mi1 tt'1i bi6t I~ minh khOng h(i i dU di~u ki¢n, t6i si: bj coi l:i. ph:) In tn;>ng tQi c:ip dQ 2.) d1 2!-l:~:fJOfJ: ~{)._~Uti&.;f:;~r,%~ir-"'L. -&5:tlliR . ~A 1<T~JHi..fl~ 5td£Ut=..X ill fiJr!1 fQ.Y1'~ (.mEJW2!lin~;
l'l:\''1, ~ ; .JJ.\ IitfJU;ii.'il;\:;zm:R · il"~·J!~J~.:f~'ii!Ji!Hiill>u'lr.'flU/11 ·l!l'l!II F~fH~HirlUJ! · I!:!Piiff!Z:.n<l · Bt.Ii~!f; · W
lll · '1:.'~ · '.!II~J t!gE. fJi:'!l:5GIJI.~E.1&W.15C • ~',A.f,'f;j;·n>m'iill!i<ii.!lo"lliii~!i'fli\lE!Nfl'il'I',;;~J£ffiHHI'i
~ULi iiTii.I!!<:!'U':: I m · ~'.A. '~IIW:rtliii'-:lli!fJ'<'FtTi'fi. ll !.\t'll m! · :li'T~'r\'l£'9lr.~Eic'FHf7J:'l'lM':Jtmill.TtUl!!fl'l'l!l:Wf}.;)=ttHim •
l.l51 Na rn f' (ApP.llido) {HQ) (!.(1:)
First Name (Nombre ) (T€n) {:-g)
Middl e Name (if any) (Sceundo nombre (si riene)
en d¢m(neu c6)
Forme r Name (Nombre anterior)
q·•l61iS ( '6~ I
(Te ncG)(I':l!'ll:161
I~C!sidcnce! AdchcH; Street Addrc ~ s and Apartment Number, City, State, and ZIP. If none, describe where you live (Do not include PO Box, R u r<:~l Rt. or bus iness address) (Domicilio: ca ll c y nUme ro de apartamcnto, Ciudad, Estado, y
C:·'ldieo r>mta l: A 1.-.lla de cstm d.:Jtos, dr.s cr ibilla l ocalid<::~d de su residencia . (No incluya el apa rt ado de correos, camino rural, ni direcciOn comercit~l.)) (Oia chi ell trU : Ten dubng va s6 PhOng, Thil nh Ph6, Tieu Bang, va Ma Bllu Oi~n .
IHiu khunp, c6, xin dien nui qlly vi"' ne•.J (KIIonr. dvqc M dla chi H(>p Thv, Oia Chi ovemg lang ho~c Oia Chi Thvang Ma;)) H!if.±ll!:!fl: : iliiSII!!!fl:'fni})l~l).£ · flj · iHW!i~%1\l;~,~ • ~IJ!l!iJi'l'f · ru'll.lWioliiJil@(jjJ!:l!\\ ( 5i'lo/Jffiillll
,,~Jf;~Wi~'/l.ll~~
t•
. ~i.9\~'!·l?;iM!..g(iTi~~tm~~tt~l.rJ :
)
/1-J I(
(Direcci6n pos tal:
Ciudad, Estado y C6digo Post<:~ I, si no cs poslble ent reg <:~rl e corresponde nd a en su domidlio). (Oj a Chi Glri Thu:
Thiln h Ph6, Tifu Bang, vii M3 Bv u Dien. r~e'u khtlng the chuyfn thll t&i dja chi Cll ngv cUa qu'(vj.) [!Ciff!lli!.Ji.: : ffi ,
Ge nd er: (Optiona l) (Sexo {O ptative)) Gi&i tfnh:(K h6ng
b~ t bu(>c
11ll'l : ( 0)/J(lj'G'f'IJ'O
Thang, Ngay, Nam) tfj~ 81111 : Fl · B · if-
• ~D!1!~1:m:M.i"iliit.1if:n':J@f.±ll!:~l: •
Hfftl!Er>i!ll~Jl;~N
Male D
Female~
(Hombre)(Nam)(ljj)
CIH;ck nppro priatc box: Marque c l
cuod ro aprop iado : D~nh d:lu vilo 6
1hich '".'P 'ldilliitnilll"ll!mi:; :
TX Driver's license No. or Personal I.D. No. (Issued by TX DPS) NUmero de
su licencia de co nduc ir de Texas ode su cedu la de ld entida d ex pedida par
e l Departam ento de Seg uridad Publ ica de Texas). SO B.ii ng L3i Xe cUa tieu
bang Texas h o~c sO ID ca nhi'l n {do BQ An Toan Lao OQng t ieu bang T exa ~
Date of Birt h: Month, Day, Year (Fec ha de
nacimie nto: mes, dia, ailo)( Ng3y th3 ng na m sanh:
(Muj cr)( Nu)(:!ci
Social Sec urity No. (la st 4 digits req uired if you do not have a driver's license or I.D. nu mber) Ntimero de
Segura Social. (Sino tien e lice ncia de conducir ni identificaciO n personal, se req uiere los Ultimos 4 nUmeros de
su seguro socia l} S6 An Sin h xa HOi (4 sO cu6i cU a sO An Sinh xa HOi dn phai c6 neu quy vj kh6ng cO sO b~ n g
la i xe h* sol D ca nhan )
U!113<3'-~i!!J ( !lnllU.T:o~Wl'fi~fA'.?.!l'ZIIli.A.5tM:!!li.£li!!i · :i'i~ff\1±3<-tliillii:
ARE YO U A U N ITED
ST ATES CITIZEN?
li.SOY C I_UDADANO/A DE LOS
ESTADOS UN IDOS'!) (QUY V!
~
(Sill Col(:ill)
D
No
(No)(Khong )(i'J)
. .
D
I have not been issu ed a TX driver' s license/
perso nal identificat ion number or Social Secu rity
Number. (No me han expedido una lice ncia de conduci r de
Texas/Cedula de identidad person al de Texas ni un Numero de
Segu ra Socia l.) ( T6i chlli! he dltQ'C cap bang lai xe cu a Texas/so
10 ca nhan ho ~ c s6 An Sinh Xa H<)i.) 'lti9.tl' TX ~!!Ttll ~.\l~}Hil!;/
@).,J~· Mllillltli\'J~U~'?t-1:iJb~fil!l
•
Precin ct No. where vot ed
. .
.
. ..
. .. .
:
~
X
Date of Election Fecha de Ia EfecciOn
Ngay Bau Cl! iYi!ll B Wl
.
Home PCT
County Clerk Ust ONLY
Per
CERT/VUID
Voter Registrar Ust ONL. Y
PCT
Jj't /
NUm. de Precinto-lugar de votaciOn/Pha n Khu na i da B'a u eli S6/i!H~!':i
'll!1.
l'l\Wll!:~
~t /
NUm. de Preci nto-inscrito para votar/Phan Khu a t d3 ghl danh so/}Rm;
tli'l.t RWl!:Wli
Type of Election Tipo de £/ecc/On
Hinh Thfrc Bau c& ill!lll:lilli'
FOR STATUS:
Author ity Conduct ing Elect ion Autoridod Adm inistrando Ia ElecciOn
Ccr Quon Th6m Quyen T/{ n H/Jnh Blw Cti .:EfifiJJf.!rllthlf
.r
I, the voter registrar/ depu ty registrar, did research the records of my office and
BALLOT CODE: :;2 L Jf._£ ~ 3.. i
i L
(Writ e in the Ballot Code, it is foun d on th e Provisional Ballot Stub above the
voter's signatu re area . The Provisiona l Ba ll ot St ub is generat ed f rom t he JBC. )
. FOR VO TERS WHO DID NOT PRESENT ACCEPTA BLE PHOTO IDENTIFICATION
1.
election day.
1.
~iled
Y61fo
D YES
t o present accepta ble f orm o f identification or voter
z.
Voter m et disability exemption within 6 da ys of e lection day.
3.
Voter executed religious objection affidavit within 6 days of election da y.
4.
Voter executed natural disaster aff idavit within 6 days of election day.
5.~
Voter did not satisfy identification or affida vit requirements, listed in
categories 1-4 above, within 6 da ys of election da y.
2.
Vote r not on list of registe red voters .
3.
Vote r not on list,
4.
5.
regf~~ered
·:a~·
in another precinct.
:
FOR VO TERS WHO VOTED PRO VISIONALL Y FOR OTHER REASONS
6.
election.
Vot er on list of peopl e who voted early by mail, and vo t er has not
cancell ed mail ba llot application .
7.
Vot ing aft er 7:00P.M. due to court ord er .
8.
Q
ln f nrmntinn n n fi i &J i n ri i r n t i n n n n nlirn nt r n rn nla tDrl
n
I U1f"cu r D n il'f" r nT i n ,
~~~IIIII~IIIIIII~IIIIII~~IIIIII~I~III~I~III~~~A~md~avi~tof~Pro~~s~ion~~v~~e~r
~~~~-~
311060035
Declaraci6n Jurada de Votante Provisional I B<'m Chtmg TM Cua Cu Tri T~m Thai I ~B~)H.~~~~
TO BE COMPLETEU BY VOT~:R: I nm a rcgistcn:ll voter of this politico! subdivision and in the precinct in which I'm attempting to vote and have not alrc<1dy voted in this election (either in person or by JlHJil). I am il resident of
this political subdivision, have not been finally ~.:onvktcll of a felony or ifu felon, I lwvc comrlctcd all of my punishment including any term of incarceration, parole, superv ision. period of probation, or I have been pardoned. I huvc
not been dctcnnincd hy n fina 1judgment of n court exerc ising prohntc jurisdiction to he totall y mcntnlly inc::~pacitatcd or partially mentally incapacitated without the right to vote. 1 undcrst~ntlthat giving f~lsc inform~\ ion under oath
is n rnisdemca:1or. ~nd I understand that it is u felony of the 2nd degree to vote in an election for which I know I am not eligible.
(PARA QUE EL VOTANTE LO L LEN£: Estoy inscrito como vutunte en cst<J subdivisiOn politica yen el precinto en cual estoy intentando u votary aun no he votrH.Io en estu clccciOn (en rn:-:ono o por correo). Soy rcsidcnte de
esta subd ivisiOn politic<~, no he sido Jdinitivnmcnte declurudo cu lpable de un del ito gmvc o si soy cl autor de un del ito grave. he cumplido toda mi condcna inclu sive el pcriodo de encurcdamiento. Ia libcrtad eomJicional. Ia lib en ad
superv isado., Ia libertad vigilndu. o he sido ind u!lado. No me h<Hl Jctcrminado por un juicio fino.ll de una corte Jc kt lcg:alizaciOn de un testamento , ser wtalmcntc incapacitado mcntalmentc o p:~rcialmcntc inc<.~pncit01do sin cl dcrccho de
vo.~ar. E~~ticndo qu~ dar inform:.~~.: iOn fabu bajo jurLlmcnto cs un de lito rncnur y tambiCn cntiendo que cs un dclito grave de 2do gra?o votarcn una cl~cci6n sabicnd~ que no cun~plo con los rcquisito~ ncecsarios.)_(Dl}{1C tiOAN TAT
BOI CU TRI: T6tlfl clr tri r.J:l ghi danh b6 phiCu t;_~i ph:in khu chinh trj dj:t phuang nfly v~ trong p!-uin khu mil t6i c6 Ydinh bO phiCu v:l chua b6 phiCu trong cu(lc b:iu L'lr nfly (kC cd dich th:Jn bO phiCu hay hi1 phiCu b!mg tim). 1'6i cu
ng1,1 t<;~i ph:in khu ehinh tri d in phuang n:ly, t6i ho;.in to{m kh6ng bi k~ttn;mg tOi ho~c n~u l;.i nguOi ph~1ntrQng t6i, t6i dil ho:i.nth:lnh h6t mQi hinh ph;;.t. han g6m thO i h:,n tU , rin trco, qufln ch~. thOi kY thlr th!ich, ho~e d;1 dm.1c tha. Ph:in
quytt cu~i citng ella tOa :in kh6ng tuyCn b6 rftng tOi_lfl nguOi mAt ho:in tofm n~ng lvc vi:: m~tt:im th~n hay mfit m(lt phfin nfing l1,1c dC t6i e6 quy~n duqc b6 phi~u. Tt"1i hi~u r~ng khai man khi tuyCn th¢ sC hi ph~m khinh t(1i, vii tOi hi~u
dng n6u bO phi6u trong mOt cu(lc bfiu clr mtl t6i biCt Iii minh khOng h(li dU ditu ki~n, t6i st! bj co i l:l ph;un trQng tQi dp dQ 2.) EEillBYJl~: *AA-Jltif!.U5tB~rA{L..g;t;ill~. -*-A~·!im£l.Mj5f~t.£Jlt:J..:ill~rfl1~W (f.Q@j!f(ffilm~
I!U'IlJ • ~'J,.Ji,\Jltil:OtifS!liiZ/bR: · tE~@l~1'lif!!ITHffiiP<JN;'f!t!JJ1 · Jl1WilrE!illEi'iill'lll · {gffifH!1;;;J · Blt~llt · ffim · ""'~ · !1Jfiii"J81!i~>t-lll~Ei&il't'l'o • *-"t't*1ll'ill'IOJ~ill!itlf!JN~1i~lE~fm'I 1 'Jt~~llllfH~
~d{tJffij~I!1\\¥!W • *-"UJ111l!:];(£HJilli!l!\'fl'Ji.'i;RlM'l!'lll · :JET!WifRm{IElc1'M'iii'H3rt:Jt~iRTIIill\!<9'1!l:l':i<'!l.::-.!JHfillll ·
First Name (Nombre) (Ten)(;?~)
Last Name (Apellido) (Ho) (i(t)
( 'G'H)
en d!m jneu c6) ~'1"9~
(Ten cO)('/';)
m:tsJ
~ ·.{._
Residence Address: Street Address and Apartment Number, City, State, and ZIP. If none, describe where you live (Do not include PO Box, Rural Rt. or business address) {Oomicilio: calle V nUmero de apartamento, Ciudad, Estado, Y
C6dlgo Postal: A falta de estos datos, describa Ia localidad de su residencia. {No incluya el apartado de correos, camino rural, ni direcci6n comerciaL)) (Oja chi elf trU: Ten dl.dtng va sO PhOng, Thanh Ph6, TiCu Bang, va Ma Blfu Dien.
Neu kh6ng c6, • in dien ta nai quy vi W ngu (Kh6ng dv(1c de dja chi Hop ThU', Oja Chi Ovi:tng Lang hojc Oja Chi Thvang Mai))
Mailing Address; City, State, and ZIP. If mail cannot be delivered to your residence address. (Direccl6n postal:
Ciudad, Estado y C6digo Postal, si noes posible entregarle correspondencia en su domicilio). {Dia Chi Glri Thll:
Thc1nh Ph6, Tieu Bang, va Ma Blfu Oi~n. Neu kh6ng the' chuyen thu t&i dja chi ell ngv cUa quy vj.) !E!Itw.tl£!11: : rtl •
JHffiffi~llifGlli~if£
Ji!iftJttlJI: :
,A- J 13 /!?u-s /rvt.
miffiffi51Jtu1Jl. Jll9flii~~-t.fi1J~illi'llu~
lfii\l(tlJI:f1l01Jl~~
Male D
(Hombre)fNam)(!/S)
TX Driver's License No. or Persona II.D . No. (Issued by TX DPS) NUmero de
su licencia de conduclr de Texas ode su cedula de ldentidad expedida par
el Departamento de Seguridad Publica de Texas). SO B~ng Lal Xe cUa tifu
'
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7
nacimiento: mes, dia, aiio)(Ngay thang nam sanh:
Thang, Ngay, Nam) :lJ!Ul WI : J'J · 13 · !f
Gender: (Optional) (Sexo (Optative)) Gl6' i tinh:(Kh6ng
bit bu(ic j<£g1J: ( "J!j~J;XOftf()
• ~O!lHFJi\lfli\\$it;ili!$B"llffif1!llilli •
Check approprialc box: Marque cl
cuadro apropiado: f):lnh d~u vao 0
thich hQ'P :(fi/ij'IJ:Jjilli*Jfllt/l.J :
· nJ · H!f1J!Iill~f\];~~ • ~Jl~!ijli'f • ID'/o~!.ffiali8Jl@j1Jttl!,i ( ffi'/o/Jfll['i\
7 ?J/ 7
Female~
(Mujcr)( Nil)(:!()
Social Security No. {last 4 digits requi red if you do not have a driver's license or I. D. number) NUmero de
Segura Social. (Sino tiene licencia de conducir ni ldentlf!caci6n personal, se requiere los Ultimos 4 nUmeros de
su seguro social) SO An Sinh xa HO i (4 sO cu6i cUa sO An Sinh xa HQi c"an ph3i cO ni!u quy vi kh6ng c6 sO b3ng
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ARE YOU A UNITED
STATES CITIZEN?
((_SOY CJU DADANO/A DE LOS
ESTADOS UNJDOS?) (QUY V )
KY KHONG?) l~lll;l:il!lil0ll':P!!l?
~DNo
CSi)( C6)(Jll:)
(No)IKh6ng)(e;')
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Texas/CedUia de identidad personal de Texas ni un NUmero de
Segura Social.) ( T6i chua he dtlt;Yc cap b~ng lai xe cua Te.as/so
ID ca nhan ho~c so An Sinh Xa Hoi.) ~59.1'f TX Wtil't~Wil9ftli!'&l
Ngay Bau Cti
•
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HomePCT
County Cluk Use ONLY
PCT
CfRT/VUIO
PCT
/
NUm. de Precinto- lugar de votaci6n/Phan Khu nai dJ B"au CU SO/ii!~m
11/5/13
!111.1lt~11t:!.l
Precinct No. where registered ________
NUm. de Precinto-inscrlto para IIOtar/Ph~m Khu no'i da ghi danh sO/ill~
!ii!111. :lHi'.lttffi
Type of Election Tipo de Eleccl6n
Hinh Th~c Bau
cu illl!l~ll\1
FOR STATUS:
Ca Quan Thiim Quyen Tien Himh Bau c& .:E/ilif!ifftlHitlf
~
the fallowing conclusian(s) was made:
BALLOT CODE: :2 L L/s-.k. ~"f' o .2.
1.
election day.
DYES
1.
c:fN6
~ed to present acceptable form of identification or voter
2.
3.
4.
5.
2.
3.
Voter executed religious objection affidavit within 6 days
s._
v_
Voter did nat satisfy identification or affidavit requirements, listed in
categories 1-4 above, within 6 days
~r not on list of registered voters.
of election day.
4 . ~ Voter executed natural disaster affidavit within 6 days of election day.
6.
L
of election day.
election .
7.
8.
9.
Information on file indica tina oooJicant com ole ted a vntPr rPni<trntinn
----------------------------------------------Case 2:13-cv-00193 Document 737-5 Filed in TXSD on 11/17/14 Page 70 of 83
TO BE COMPLETEU BY VOTER: I am a registered voter of this po litic31 subdiv ision and in the precinct in whi ch t·m ancmpting to vote nnd have not already vo ted in this election (either in person or by mai l). l am a rc5idcnt of
th is politica l subdi visio n, have not been finally convicted of a fe lony or if a fe lon, I have completed all o f my runi sh ment including any term of incarcera tion, paro le, superv isio n, period ofprob:uion, or I have been pardoned. I have
not been determined by a final judgment of a court exercising proba te jurisdiction to be totall y menta lly incapac it ated or partial ly mcntn lly incapacitated withou t the right to vote. J understand that giving fn lsc infonn:l\ion under oath
is a misdeme<1:10r, :md I understand that it is a felony oft he 2nd dcgrc_c to vote in an elect ion fo r wh ich I know I am no t eligible.
(P,\RA QUE EL VOTANTE LO LLENE: Estoy insc rilo como vo tant e en est a subd ivisi6n polit ic a yen el prccinto en cua l estoy int enta nf.Io a votary aun no he votado en est a elecc i6n (en persona o por correo). Soy rcsidentc de
cst:J subd ivisi6n potltica, no he sido definit ivamente dcclarado culpable de un del ito grave o si soy el autor de un de lito gra ve, he cumplido toda mi co ndcna inclusive cl periodo de cnca rcclam icnto, Ia libertad cond iciona l. 1:1 libcrtad
supcrv isada, Ia libcrtad vig il ada, o he sido indull ado. No me han detcrminado par unjuieio fin al de una corte de Ia lega lizaci6n de un testamento , scr tot.almentc inca pacitado mcntalmentc o parcial mente incapacitado sin cl dcrccho de
volar. Enticndo que dar infonnoci6n fnlsa bajo juramenta cs un delito mcnor y tambiCn cntiendo que es un del ito grave de 2do grado volar en una elccc i6n sabicndo qu e no cumplo con los requisitos necesarios.) (OU"QC HOAN TAT
BO'J Clf TR I: T6i Iii ell tri dil ghi danh bO phiCu t{l. i phrin khu ch inh tri dja. ph Liang mi.r v~ trong ph:in khu tmi tOi c6 y djnh b6 phi~u v:'t chua bO phi~ u trong cuQc b:lu ell n:iy (k6 d. dlch thfm bO ph i~u hay bO ph i~ u bnng till!). Til i cLI
ngv 1\li ph<in khu chinh lrj dja pllllcmg nily, t6i hoi:mtoiln kh6ng bj kt t trQng tQi ho~c nCu l:i nguOi ph\lm trQng tQ i, tOi d:l hoiln th~nh h~l mQi hi nh ph\11, bno gbm thOi h~;~n tU, On treo, qu :in ch~. thOi kY thir thlic h, ho~c d::l dLIQC tha. Philn
quy~t cu6i cUng elm tOa On kh6ng tuyC n bb r~ng tOi 1<\ nguOi m6t hoim toiln n~ ng l\fc v~ m~t tilm th:in h::~ y mAt rnQt ph~n n3ng lvc d~ tbi c6 quyt n dLIQC b6 phi~u. TOi hi~u r~ng kha i man khi tu yC n th~ sC bj phQm kh in h tQi, v:i t6i h i~u
ring n~u b6 phiiu lrong mo l CUQC bfiu eli,; t6 i bifl 13 mlnh khong h(li du diiu ki¢n, t6i '~ bi coi J; ph.m lrQng lQi dp dQ 2.) BJillti:lJU!!: ~-Al::luti&i[;flii&i"J :Log;t;il!R. <$:Ai\I:lil'mi.l3.f\ll*ti!lt=):iJII!!1'l'.H\'I i!<li3;jl([<f,llf
JIJWI • ~;_A!MtifJU!S:filiilliZ/i!iR · b't;J<~JlH~~'llHfii'IIHlH¥£;JE · ;ji(QfJUJ!WJ[lff!fl!ll' · {QJ'Ji#11\li'l · §ttiiiiJ~ · ®tw · iiii'ft · !l'lWJf;JeJlt~7'C.1!>!1<e·IJiilfJ(!C • ot.:Ab't*11iiil1!Jil~fflliidJ1li'lt·¥lil:l£1IJfi'M%:i:ll£ilill)}l~
!l<ft;JJifri!i\lll!~ffl • *ABJl~£1~i!ifi~IJHf!~,R~I!l!>Jl · 1HMtiBJl~ Eic1'N'.g'i'lf3091P/i5tr1:Eilllll9' tllJ'Ill::l=t&!fl~ ·
Last Name (Apell ido)(HQ) (i(J:)
First Name (Nomb re)(Tfn) (o8,)
en d~m (neu c6)
<Pro1;!'; ( i'i# I
(Ten cuiC'<Ifll;!\)
{
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Residence Address: Street Address and Apartment Number, City, State, :and ZIP. If none, descri be where you live (Do not include PO Box, Rural Rt . or business address) (Oomidlio: calle y nUmero de apartamento, Ciudad, Es tado, y
C6dlgo Postal : A falt a de estos datos, describa Ia localidad de su residenc ia. {No incluya el apartado de correos, cam ino rural, ni direcci6n comercia l.)) (Dja chi ctl trU: Ten duOng va sO PhOng, Th3nh Ph6, Tie u Bang, v3 Ma Buu oien.
Neu khong c6, xin di~n ta nai qvyvi w ngv (Kh6ng dv<;tc de dia chi H6p Thll, Ilia Chi Ovlmg Lang ho~c ll ja Chi Thvang M9i) )l§{1lt!;l]!: : i.!i-'!',lftljl:*iJi};!i!~R · 1fi · rli:[{Jli!l'&Hll; ~}l • ~JiliJ!*J · lHn~WJiliBJlJ:!i{Xlt!;ll'; ( ffi'/o/Jilllill
FoilrHfi'ii,£!il!j • ~ilHH&~~llli~illi'l!1JililJI:)
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Mailing Address: City, Sta te, and ZIP. If mail cannot be delivered to your residence address . {Direcci6n posta l:
Ciudad, Estado y C6digo Postal, si no es posible entregarle corresponden cia e n su dom lcllio). (D ia Chi Glti Th u :
Thanh Ph 6, rieu Bang, va M:i Buu Dien. Ne"u kh6ng the chuyfn thll tOi dia chi cll ngv cUa quy vi.) !mmt:t~iJ.l: : ffi ·
Hlftl!E!lil'Hll!~Jt
nacimiento: mes, d la, afl o)(Ngay th3ng n~m sanh:
Thang, Ngay, Nlm) tfj~ BWJ : Fl · 8 · fl'
• JzO!U11'i!fliilitilm![:fl'JJi!ittlililJI: •
MaleD
(Hombre)(Nam)(!Jj)
Check appropriate box.: Mnrque el
cuadro apropiado: Oinh d5.u vim 6
thich h\>P tiiNi!tnt3F'lilJ111:.J :
TX Dri ver's license No. or Persona l I. D. No . {Issued by TX OPS) NUmero de
su licencia de conducir de Texas o de su cedula de ldentidad expedid a por
el Departamento de Seguridad Publica de Texas). SO B~ng La i Xe cUa tieu
.
•
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¥ (} <6; )_<£_I !9:_ 2_ 3
Female
(Mujer)( NO)(;!{)
Social Security No. (last 4 digits required if you do not have a driver's licen se or I. D. number ) NUmero de
Segura Social. (Sino tiene licencia de conducir ni identificacl6n persona l, se req ulere los Ultlmos 4 nUmeros de
su seguro soc ial) 56 An Sinh xa HOi (4 s6 cu6i cUa sO An Sinh Xii HQi tan phil I c6 n€u qu'( vi khOng c6 s6 bang
:
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ARE YOU A UNITED
STATES CITIZEN?
C•SOY CIUDADANO/A DE LOS
EST ADOS UNIDOS ?) (QUY . VJ
CO PH Al LA CONG DAN HOA
KY KHCNG'!) !.2!fi1:~1m}~;B:;IIf.5?
~DNa
1Sii(C6)(;1!1:)
(No)(Kh6ng)( '3')
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OO.A.!ti7J~fliltft~!i1\tHHt~~~
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N g ~ y Bau Cv ii!l!!BW!
f
Seguro Social.) ( Toi chva he d11<;1c cap b~ n g lai xe cua Texas/so
ID ca nhan ho~c so An Sinh Xa Hoi.) tt).(ifj TX 'm~f.i\~.ll5iltU!!i/
Home Per
County Clerk Us~ ONLY
Per
CERT/VUID
Voter Registrar USt! ONLY
PCT
NUm . de Precinto-tugar de votaci6n/Phan Khu nO'i d~ B3u Clt 50/Ui~tfi
'i\'f. IJI:~Jili:M
Precinct No. where registered ---,-O_S--:::-'1-:-I"'j2.-,--::-::::
NUm. de Prec into-inscrito para vota r/P h:i n Khu nO'I da ghl danh sO/}g~
!I;'i\'1. !Hctfu!M
Hinh Thlfc Bau
iill!!lill1!2
cv
FOR STATUS:
Authority Conducting Election Autoridad Administrando Ia Eleccicin
Cu Quan Th6m Quyen Tien Himh Bau Cti' .:E/ifil!!.$111#1
the following conc/usion(s) was mode:
BALLOT CODE:
J.! Co .J _j 1:. ).. .2.1
voter's signature area. The Provisional Ballot Stub is generated from t he JBC.)
1.
election day.
VOTER PRESENTED ACCEPTABLE FOR,OF IDENTIFICATION
0 YES
l._j_
fJ
NO
Failed t o present acceptable form of identification or voter
2.
3.
Voter executed religious objection affidavit within 6 days of election day .
4.
Voter executed natural disaster affidavit within 6 days of election da y.
s.7
categories 1-4 above, within 6 days af election day.
2.
3.
4.
·6.
Not o registered voter or registration. not effective in time for this
election.
cancelled mail ballot'application.
5.
FOR VOTERS WHO VOTED PROV/S/ONALL Y FOR OTHER REASONS
7.
Registered to vote, erroneously fisted in wrong precinct.
8.
Q
lnfnrmntinn nn fi/p inrlirn tinn nnnlirnnt rrH"Yinlateu-1,
untPr
rarric trntinn
IIIJJJI JIIJI//JI///J// J/J///JIII ///J/ IJ/// 11//J/J/J/JJ/
311473009
Declaraci6n Jurada de Votante Provisional I Bim Chung TM Cua Cu Tri T:;tm Thai I ~~~~J~J~:tl
~AA
TO BE COi\IPLETED BY VOTER: I nm a registered voter of this political subdivision and in the precinct in which I'm attempting to vole and have not already voted in this election (either in person or by mail). I am a resident of
this political subdivision, have not been finally convicted of a felony or if a felon, I have completed atl of my punishment including any term of incarceration, parole, supervision, period of probation, or I have been pardoned. I have
not been determined by a final judgment of a court exercising probate jurisdiction to be totally mentally incapacitated or partially mentally incapacitated without the right to vote. I understand that giving fal se information und er oath
is a misdemeanor, and I understand that it is a felony of the 2nd degree to vote in an election for which 1 know 1 :1m not eligible.
(PARA QUE EL VOTAI'I'TE LO LLENE: Estoy inscrito como vota11tc en est a subllivisiOn politica yen cl precinto en cual cstoy intentando a votary aun no he votado en esta elecci6n (en persona o por correo). Soy residente de
csto-subcl)\'isi6n polit ica, no he sido dcfinit ivamcnte dcclarado culpabk de un del ito grave o si soy cl autor de un dclilu gr<~ve, he cumplido toda mi condena inclu sive cl pcriodo de encarcclamicnto, Ia libenad condicional, Ia libcrtad
supcr•isada. Ia libcrtad vigilada, o he sido indultado. No me han dctcrminado por un juicio ftnal de una corte de IJ kg<~liz<.~ciOn de un tcstamlcnto, scr tol<~lmcntc incapacitado mcntalmcnle o parcial mente incapacitado sin cl dcrccho de
votar. E_~ticndo que dnr informaciOn falsa bnjo juramenta es un de lito mt:nor y tambiCn cnticndo que cs un dclito grave de 2do gra~o vot:.~r en una d~cci6n sabicnd£? que no cu~plo con los requisite~ ncccsarios.) (Dl:J"OC HOAN TAT
Bdl CU'TRI: T6i lil cir tri dii. ghi danh bO phiCu t~i ph<ln khu chinh tr! dja pluwng n:iy vit trong ph6n khu mil t6i c6 y djnh bO phiCu v:l chua bO phiCu trong cuQe b5u clr nily (ked dich th3n bO phiCu hay bO phitu b1ing thu). T6i cu
ngv t:_1i phOn klm chinh trj dja phum1g n:i.y. t6i ho<ln toi:m kh6ng bj k~t tn;>ng tQi ho~c n6u 1<1 ngu&i ph~tm tr9ng t9i, t6i dii ho;jn thimh h~t lllQi hinh ph~t, baa g6m thOi h(ln tU, im trco, qudn ch~, thc7i k)' thir th<ich, ho~c dii duqc tha. P~dn
quy~t cu6i cUng cUa tOa lin kh6ng tuyCn b6 r~ng 16i la nguCri m5t ho3n to:in n;1ng l11c v~ m~t t<lmthAn hay mAt mQt ph~n nilng ii!C d~ t6i c6 quy~n duqc bO phi~u. TOi hi~u rftng khni man khi tuyen th¢ sC bj ph;,~m khinh tQi, vii tOi hiCu
r&ng nin bo phi~u trong m9t cu(>c biu cl1 ma toi bi~t Ia minh khong h(ii de• di6u ki¢n , toi sc bi coi Ia ph?m tr0ng toi dp d9 2.) r!Jil![\'lJ(f<!,: ~'),.lotlti&oaf/il;]!;f'JZiroiiil!R, 'I' A 'R:l:t!lli.ElMl*<'Efrt:),:jl!!IJ'f'lll~~ (~Jl.§~lJili;if
t~>'WI • ~<A.:MtiE.i::ai'lii®:Z.IiS~. l!t*l!;ll81'fili:mHmi&lll1\~JE:r.. ~~nl'l'*lmJ\il!Oil' · &fiJiJ\ii!;iiiJ · §tli'iliir1: · mm · \liilf · ~ifu~eti!~iMl>~eJ&i!2t;t • :.t'Att*i&il:l'!ll~ill;tJE®i'fn'<JE:!Zl~ml'I''J'G:'E~ll!ll})l!I
5\:IJE.:I:Jlfii!i\\!fr'.\'!!t/i • :4•A"Jllll!ll:1;1iHJI:I!Fi-1lt'i!i1HMl<P · 1ii.Tfl.HfBJl'WE121'H<5l'H~6'Jtlio5L T tEilltll'f'I!!:~L1"l=tiH!l:Jll •
First Name {Nombre) (Ti!n) (;g)
Last Name !Apellido) (Hoi (ll£)
en d~m (neu c6)
former Name (Nombre anterior)
(Ten cO) CWI1li\)
'i'ro1og ( :S*l l
f'Ylarc..l~.// e.
Residence Address: Street Address and Apartment Number, City, State, and ZIP. If none, describe where you live (Do not include PO Box, Rural Rt. or business address) (Domicilio: calle y nUmero de apartamento, Ciudad, Estado, y
C6digo Postal: A falta de estos datos, describa Ia localidad de su residencia. (No incluya el apartado de com~os, camino rural, ni direcci6n comercial.)) (Dia chi ell trU: Ten dvOng va s6 Phbng, Thanh Ph6, Tii!u Bang, va M3 Bllu men.
Neu khong co, xin dien ta ncti quy vi w ngv (Khong dlfoc de d)a chi H9p Thu, o;a Chi Dltlmg Lang ho~c Dia Chi Thlfong Mail) ffil±l~lll: : ifl>6lili!J!:f.ll0m~R · ill · i+lf.ll!!\B'*I.l'f'iil1 • ~ll!l<;Jl*J • lnft¥i!lll\tRJlffi[1Jililll'i ( ffi'Jo/.Jffi\'ill
FoJr:;;rii>1!16!'l · lil>ms~-~oguG~Mii!!tMt 1
a cite.
Mailing Address: City, State, and ZIP. If mail cannot be delivered to your residence address. (Direcci6n postal:
Ciudad, Estado y C6digo Postal, si no es posible entregarle correspondencia en su domicillo). (Dja Chi Glti Thll:
Th.3nh Ph6, Tieu Bang, va Ma BLiu Dif~n. Neu kh6ng the chuyen thll t&i dja chi cU' ngu cUa quo{ vi.) !@~tllihl : rtJ '
!'11'lfi!FI\i~(;ii;9H
Gender: (Optional) (Sexo (Optativo)) Gi6'i tinh:(Kh6ng
blt buoc j<£~'1: ( iiJl.ii~:or-tJ:O
• iiU~!lt~*!il\ot.lliiit'i!JA"J/51±1~±J!: •
Check approprialc box: Marque el
cuadro apropiado: Dtmh ddu vilo 6
thich hl/]l :ffi@'li\;/Jjl\F'J!lliJi:J :
ARE YOU A UNITED
STATES CITIZEN?
( 0SOY CIUDADANOIA DE LOS
c6 PHAI LA C6NG DAN HOA
0
(Si)( C6)(l>::J
No
(No)(Kh6ng)@)
TX Driver's License No. or Personal LD. No. (Issued by TX DPS) Nlrmero de
su licencia de conducir de Texas ode su cedula de ldentidad expedida par
el Departamento de Seguridad Publica de Texas). SO Bang l<li Xe cUa tie!u
bang Texas ho~c s6 ID ca nh3n (do BO An Toan lao DOng tieu bang Texcis
.
Male 0
Female W
!Hombre)(Nam)(lfl)
(Mujcr)( Nfr)(ft:)
j_ !_ I ___!_ _!____ I _j_ 1_
II-
Segura Social. (Sino tiene licencla de conducir ni identificaci6n personal, se requiere los Ultimos 4 nUmeros de
su seguro social) 56 An Sinh X.ii HQi (4 sO cu61 cUa s6 An Sinh X.ii HOi din phfli c6 neu quy vj kh6ng cO s6 b3ng
Iii xe hole solD ca nhan)
l±~Clt:i:IJVffi!ll ( ~O!l<!if:oJ!J\i.I.Jt!l'fM~~IIllA~f7iKI!I<Rfi!ll · l~t1mt±Clt-H'<It:
. -. - .
..
..
.
.. .
.. .
Texas/Cedtila de identidad personal de Texas ni un Ntimero de
Segura Social.) 1Toi chua he auQ'c c~ bang lai xe ctla Texas/so
ID ca nhan ho~c s6 An Sinh Xa H(li.) :J'\ti£1'! TX ]!,~J!Tf)l~?,ili!<Ol!l/
ll?l.A!l'Mili>m0l!l~U~3i'3':\ff!li\'j
•
Date of Election Fecha de fa Efeccidn
Ngay Bau Cti ~!!! EIWJ
nacimiento: mes, dia, ai'io)(Ngay th<lng nam sanh:
Thang, Ngay, Nam) l±l!t El Wl : fl · El • "f
/
HomePCT
PCT
CfRT/VUID
Vater Registrar Use ONLY
PCT
Z/3
Nlrm. de Precinto-lugar de votaci6n/Phan Khu nai da B"au Clr S6/ill~_Hifii
~k
ll!:!lliltM\1
-:-::--'/-""2;~:'6.:"--,--7.:::
Nlrm. de Precinto-inscrito para votar/Phan Khu nai da ghi danh s6/jli;l&
!>Hk
Hinh Thirc Bau ClJ' ill!lll>i~
ftllc>~i'll
FOR STATUS:
Authority Conducting Election Autoridad Adminisrrondo Ia E/eccidn
ca Quan Th6m Quyen Tie'n HOnh BDu CLi .Ef.fiififfm!Pf
BALLOT CODE:
1.
Voter presented acceptab le form of identification within 6 days of
election day.
0 YES
l. v'
D NO
2.
3.
Vater execut;,d religious objection affidavit within 6 days of election day.
4.
5.
7
2.
Voter not on lis t of registered voters.
3.
4.
6.
election.
5.
FOR VOTERS WHO VOTED PROVI5/0NALL Y FOR OTHER REASONS
7.
8.
9.
Information on file indicatina aoalicnnt rnmniPtPrl n vntPr rpnir:trntinn
- -- - - - - -·- - - - - - - -
l lllllllllllllllllllllllllllllllllllllllllllllllllllll
311473018
Declaraci6n Jurada de Votante Provisional I Ban Ch(rng TM Cua Cu Tri T~m Thai I lm~~~~~-
TO BE COMPLETED BY VOTER: I am a registered voter of this political subdivision and in the precinct in which I'm auempting to vote and have not already voted in this election (either in person or by mail). I am a resident of
this political subdivision, have not been finally convicted of a felony or if a felon , I have completed all of my punishment including any term of incarceration, parole, supervision, period of proba tion, or !"have been pardoned. I have
not been determined by n linal judgment of a court ~:xcrcising probate jurisdiction to be totally mentally incapacitated or panially mentally incapacitated without the right Ill vote. I understand that giving fnlsc infommtion under oath
is a misdcmc~nor, and I understand tho t it is o felony of the 2ntl degree to vote in an election for which I know I am not eligible.
(PARA QUE El VOTANTE LO LLENE: Estoy inscrito como votonte en csta subd ivisiOn politica yen cl prccinto en euol cstoy intentando a votary nun no he votado en esta elecci6n (en persona o par correo). Soy rcsidente de
est a subd ivisiOn politica. no he sido dcfinit iva mente dcclarndo culpable de un de lito grave o si soy e l au tor de un de lito grave. he cump lido toda mi condcna inclus ive cl pcriodo de cnca rcclamicnto, Ia lihcrt ad condiciona l. Ia libcrtad
superv i sad:.~, Ia libcr1ad vigi l:.uJa, o he sido indultado. No me han dcterminado ror un juicio tina! de unn co rt e de Ia lcgnlizacic'm de Llll testamento, ser totulmcntc incapLlcitado mentalmcntc o porcialmcntc incupnc itado sin cl dcrccho de
vo.tar. E.~ticmJo que da r informaciOn fa lsa bajo jummcnto cs un de lit o mcnor y tarnbiCn cnticndo que es un de lito grave de 2c.lo gra~o vota r en una e l~cciOn sabicnd~ que no cur~plo con los requisite~ nccc~arios .). (DY'<.JC HOAN TAT
801 CU TRI: T6i 13 eli tri dU ghi danh b6 phicu ti,li ph:in khu chinh trj dja phuong nay villrong ph:in khu m:J t6i c6 ydjnh bO phiCu v:l chua bO phiCu trong cu(H: biiu clr nily (k~ cJ dlch thfm bO phiCu hay bO phi~u b~ng th11). TOi cu
ng1,1 t~i phiin khu chinh trj diLl phuang nily, t6i ho:ln toiln kh6ng bi k&t trQng tQi ho~c n~u l:J ng1.nli ph~m tn;mg tQi, tOi dii. hotin th3nh h~t mQi hinh phi,! I. bao g6m thCri h~n tU. an treo, qu:in ch~, th&i k)r thlr th<ich, ho~c dfi duqc tha. Phcin
quyt t cu6i cUng cUa tOn tin kh6ng tuyCn b~ dng tOi Ia ngu<:ri mAt hoiln toim nOng h,rc vt. m~t tilm th~n ha y mjt mQt ph~n nilng lvc d~ t6i cO quy~n duqc bO phi~u. T6i hi~u dng khai man khi tuyCn th¢ sC bj phQ.m khinh tQi, vilt6i hi~u
dng n~u bO rhi~utro ng ml)t cuQc b5u clr mil t6i bi~tl3 minh kh6ng hOi dU di6u ki~n. t6i sC bi coi l:i Plwm tn,mg t(>i dp dQ 2.) FHU!~tJl1m: :.1-:Al.?t!ti&::f5fJ{;lli r.tgz.g;tm~ . *A~1!~.13..f'Sl*{fltt:)CUHfltp1~H.i (f~El~[!J1*
ll!i'lil • ;r-A.t\tltiP.!ifuf,HZZ@I"'. · ~~<fiil18:J;i!f!~~jjjj/I>L';)~¥JE:lll! · 0WIIIiHHE1'fDiUH · IQJ'Ji1IfiZ:oi:iiJ · §12i'Mil~1 ·
~'lif · !:llJ~ll!JBffl~!Jt:~~!l'iJ~l!Ji;l!l!'.e • :.4<A~~<ll!iill'llliiiil!itlliul<~¥r/IJE!i§*m'i''!C:'i:!i'Zlli\1Hi".l
!l<tiE:IJfffihiillt~IM • :.4<)..AAi~:E'Ii11!ttliH!\4-1'l'~~l\.MJ!:W · ;ltCTW11':E'!!l9:!1Elc4-ff~i''iTJ(!'Jffl;5CF:fril! !I!<Pifr~l!l.::U!JU1 •
rum ·
Last Name (Ape llidoJ (Hoi (i(£)
First Name {Nombre) (Ten) (cf,)
Name (if a ny) (Segundo nombre (si tiene)
dem (neu
Name (Nomb re anterior)
cuf(jli/1lcf,)
c6) <f'ro1cf> ( '5#)
Nora
Residence Address: Street Address and Apartment Number, City, State, and ZIP . If none, describe where you live (Do not include PO Box, Rural Rt. or business address) (Oomicilio: calle y nUmero de apartamento, Ciudad, Estado, y
C6digo Postal: A falta de estes datos , describa Ia localidad de su residencia . (No incluya el apartado de correos, camino rural, ni direcci6n comerciai.J) (Dja chi elf tnt Ten duOng va sO PhOng, Thanh PhD, Tieu Bang, vill Ma Bllu Dien.
Neu khong co, xin dien
1:\i{g>fi'll/i'!l ·
ta noi quy vi w ngu (Khong dlfoc de dia chi Hop Thll, Dia Ch i Dlfb'ng lang ho~c Dia Chi Thlfong Mail 1@{lltthl: :
n9Hi1lt~,g,I,T,~il'!i~,£JttJ!l:
fjjcf>lttiJU110lil'lll ·
m· i'H11l!<~lltl]l;~R • ~nllti5l.#
· i!)nfMifJIBA@f±ltti~\ ( 5f)VJF!I!IHI
l
77~0/
Malting Address: City, State, and ZIP.
i cannot
to your residence address.
Ciudad, Estado y C6digo Postal, si noes posible entregarle correspondencia en su domici lio). (Oja Chi Glri Thlf:
Thanh Ph6, Tifu Bang, va M3 Bvu Oien. Ne'u kh6ng thf chuye'n thlf t&i dja chi cLt ngv cUa quVvi.) ~*'f\!!.ftl: : ffi ·
tfi;f1Ji11~rn;'lH
Date of Birth: Mon th, Day, Year (Fecha de
nacimiento: mes, dia, ailo){Ngay thcing nam sanh:
Thang, Ngay, NamJ tU~ B Wl : J'l · B · if
bat buOc tifliJ:
• l!!JJ!l,m1tf!iiiitiiiiii!il:(!'Jfi!H!l~IJI: •
Male D
(HombreJ(Nam)(!Jl)
Check appropri:ltc box: Marque cl
cuadro aproriado: 1:1ilnh diu vi10 6
1hich h\7P {Eil'l'ii\·ntW'II!l'li"i :
Female [J./'
_1 _j_ 1--'1 _!:/1_j_ _g_ S 5
(Mujcr)( Nit)(;!()
Social Secu rity No. (last 4 digits required if you do not have a driver's license or J.D. number) NUmero de
Segura Social. (Sino tiene lice ncia de c:onducir ni identifica ci6n personal, se requiere los Uitimos 4 nUmeros de
su seguro social) SO An Sin h xa HOI (4 sO cuOi cUa sO An Sinh xa HOi can ph~i c6 neu quy vi kh6ng c6 sO
l<ii xe
sO ID ca
ill''llli!IJ\1'i'liH"IM1.!i
ARE YOU A UNITED
STATES CITIZEN?
(;,SOY CJUDADANO/A DE LOS
F.STADOS UNIDOS?) (QUY V !
KY KH6NG!) !~U~:~I!lli~L\:Ilm?
Q..{es
0
No
(S i)(C6)(~)
per
Dare of Eledion Fecha de Ia Elecci6n
Ngay Bau Cil illl!l 8 WJ
/
'Z ~
NUm. de Precinto-lugar de votaci6n/Phim Khu nai d3 B3u CV SO/UJ~~
~}(
lll:i'iiltt!l\1
CERT/VUID
/,_Z
_ _.f{"'----,-,-
6/~
Precinct No. where registered __
NUm . de Precinto-inscrito para votar/Phan Khu no-ida ghi danh sO/ii!~
!Jill!,~.
Type of Election Tipo de £Jecci6n
Hinh Thlic Bau Cil illlll:r:liil:!
PCT
:ll'•m:M
FOR STATUS:
Authority Conducting Election Autoridod Administrondo Ia Elecci6n
Cr1 Quan Th6m Quyen Tien Himh Biiu eli :Efififfiit/JJ/;If
~rrc'
J, the voter registrar/deputy registrar, did research the records of my office and
BALLOT CODE:
l g 25'3'1-'. j .!:J
voter's signature area. The Provisiona l Ballot Stub is generated from the JBC.)
l.
election day.
0 YES
1.
01Jo
,..-/ Failed to present acceptable form of identification or voter
certificate with exe mption.
2.
3.
4.---j
s..JL_
2.
3.
4.
5.
cancelled mai l ballot application.
6.
election.
7.
B.
9.
information on file indicatina aoo/icant como/eted a voter reaistration
.
,,
.
311484033
Declaracion Jurada de Votante Provisional I Bim Chtmg TM Cua Ctr Tri T1;1m Thai I Wo~ii~JUa~
TO BE COMP LETED BY VOTER: I am a registered votcro fthis polit ical subdivision and in the precinct in whi ch I'm anempting to vote and have not alrc:udy voted in this elect ion (either in pcrson or by mail). I am a res ident of
this pol it ical subdi vision, have not been finall y convic ted of D felony or if a felon, I have completed all o f my punishment including any term of incarceration, paro le, supervision, period of probatio n, or I have been p:.~ rdoncd. I ho ve
not been determined by a fina l judgmem ofil coun exerc ising probate jurisdiction to be tota ll y menta lly incapacit:ncd or p:mi:11ly mental ly incapacitated without the right to vote. I understand that giving fa lse information under oath
is a mi.~dcme.::m or, anrl I understand that it is a felony of the 2nd degree to vote in nn election for whic h I know I am not eli gible.
(PAHA QUE £L VOTANTE LO LLENE: Estoy insc rito como vo tantc en csta subdivisiO n politica ye n c! prccinto en cua l estoy intcntando a volar y aun no he votado en csta clccciOn (en persona o par corrco). Soy rcsidcntc de
est a su bdivisiO n pol it ica. no he sido de fin it ivnmcntc dcc lnrado culpab le de un dclito grave o si soy d autor de u11 de lit o grave. he cumpl ido todu mi condcm.l in cl usive cl period a de cncarcclamicnto, la Iibert ad condicionul, Ia libc nod
supcrvisadu, li1 li bcrtud vigiludn, o he sido induh odo. No me hun dct crm im1 do par un juicio final de una c:orlc de Ia lcgo li%aci0 n de un testamento, scr totnlmcntc in copucitado mcnt;llmcntc o parcir~lmcntc incor>acitado :;i n d 1krccho de
vo lar. Enticndo que dar informaciOn fal.~u bajo juramenta cs un de lito me nor y tambiCn cntiendo que cs un del ito gra ve Jc 2do grJdo volar en una elecc iOn S<~bicntl o que no cump lo ~:o n los requis ites m.:~.:csa rios.) (OU'OC HOAN TA'r
B61 ClY TRJ: TUi I ~ ~..:lr tri t.lii ghi danh bU phiCu t<.Li rh<in khu chinh tri ~ia phuung mly vii \rung ph;1n khu mil tUi ct'l Ydjnh bO ph ie u vil dHia bU phi~u trong cu<,)c bfiu cir na y (k~ ell d!ch thim bO phi~ll hny h<i phi~u b:ing tlm). Tlii ctr
ng1,1 t<.li ph<'111 khu ch!nh trj d ja phuang nily, t6i ho6n toim kh6ng bi k~t trQng tOi ho~c n~u 13 ngu6'i ph~m tn,mp ti)i. tOi t..lil hoDn tl1tlnh h~tmoi h!nh ph\lt. bao g6m thOi h~;~n tU. <i n trco, qulin ch6, thOi kY thlr th:ich. ho~c dfi cluQ"c tha. Ph:'m
quy6t cuOi cU ng ella t6a :ln kh6ng tuyen b6 rfing tOi IU nguO'i mf.t hm\n toim n~ ng h,rc v6 m~ttlim thdn hay m:it m(lt ph}n nang h,rc d~ tOi c6 quy~n dHQ'C bO phi~u . T6i hi~u n~ng khai mnn khi tuyCn th¢ sC bj ptwm khin h t¢i. vU tili hi~ u
dtng n~u b6 ph i6u trong mQ1 cuc) c b5u clr m:i t6i biett:i minh kh6ng hQi dU di~u k i~ n. t6i se bt coi l:i ph\lm trong tQi dp dQ 2.) ffiill~t)'J;~: ~;.:)..~lH:d::1:5EifSI;!t;f-~.Z.g.;~ru~. ~i:)..fi1!nfi13..fc;j*1fllt:.X.ll!IUcf4~~!J; (~El~!lill1!f
tl!:Wl • ~'AiOJttiliU;f~rn;zgt;:: · !;'E*f§·l8'i'iifHI1ifT1illifi!)~lE!Jil · !i'<~I!Cfi!IJ[l'IHil"W · !!!ffiNJ01iiil · §h~rhiJW · lk~l'11 · lli£'1[" • !!lil'Jl!JeJli~~!JJ.;;xeJeiWt~. • ~A!;'E*i!Z il'llfillii:l!>t;ll!fi',!!;1&lEilji1'/1'1 1 3i'.{l':!i'<ffi',fl11'1!
!Ji:lit;IJffn!RIIltV,'illl • 'I'A"JliliU>:i!H!\Ii£1Jl.'f'i'!~SR~fi;Jl · :iETfWt£RJJ1JJ§le'!'Ft~lil'1~(l":Jiil/;JrF:ffilllfl'1'1lti.ilO=~ill;Jl·
last Name (Apellido) (HQ) (i(£)
Middle Name (if any ) (Segundo nombre (si t iene)
First Name (Nomb re) (Tenl (:!',)
en d~m (neu e6) <Pro~~
( :5~)
(Ten eu) (tl Ill:!'.)
c~J
E
Residence Address: Street Address and Apartment Number, City, State, and ZIP. tf none, describe where you live (Do not include PO Box, Rural Rt. or business address) (Oomicilio: callc y nUmero de apart amento, Ciudad, Estado, y
C6digo Postal: A falta de estes datos, describa Ia loca lidad de su residencia. (No incl uya el apartado de correos, camino rural, ni direcciOn comercial.)) {Oja chi elf tni: Ten dU'b'ng vil sO PhOng, Thanh PhD, Tieu Bang, va Ma Bllu men.
Neu khong e6, xin di~n ta nai quyvi w ngv (Kh6ng dll~e di' dia chi Hop Th11, Oia Chi 011img Lang hole Oia Chi Thllang Mlil) @[llt!!!J!: : l:li:!'.ll!!trl:11J0)j!;,)f · ;ji · !HTU!Iiii~'Hl;;ilR • M!l!i§l.=!i' · ffi'l~¥!l!IID/f9J@I1:Jt!!L~i ( ID!II!iJfTJffi~
I'Jii~::iii~R~!!l
·
~1191·i,~AA!~!Ill!i'<illi'i.~tt!!tJ!:)
Malllng Address: City, Sta te, and ZIP. If ma il cannot be del i ered to your residence ad dress. (DirectiOn postal:
Ciudad, Estado v C6digo Postal, si noes posible entregarle correspondencia en su· dom icilio). {Oja Chi Gti'i Thlt:
Th<'ln h Ph6, Tieu Bang, vc'l Ma Bllu O i~ n . Ne"u kh6ng the chuyen thll t&i d ja ch i Cll ngv ella qu'( vj.) !H~~j\ttt : ili •
t/i11J['ill!.l!1l;'l,~
Gender: (Optiona l) {Sexo {Optativo)) Gi&i tinh :(K h6ng
( O)IJ'!Jii,'f-1:1[)
blt buOe ft~IJ;
• MJI!['il;lf!RI;tJtiii!&:B'Jii!lftllttrl: •
Male D
(Hombrei(Nam)(Jil)
Check nppro printc box: Marque cl
cuadro apropiado: D:inh dfiu v:io 6
lhich h\JP li~1li:JJt3i"JilJlJ1:)
:
ARE YOU A UNITED
STATES CIT IZEN?
!;,SOY CfU DADANO/A DE LOS
ESTADOS UN fDOS'!) (QUY V!
CO PHAI LA C6NG DAN HOA
KY KH6NG '!) !.2! ·.(2!k!tij~.HX:II.~?
~Yes
D
!Si)( C6)(jll)
No
(N o)(Khong)(i§)
(Mujcr)( Nu)(:!!;)
el Departam en to de Seguridad Publica de Texas) . SO B3ng liii Xe cUa tieu
bang Texas ho~c sO ID ca nh~n (do BO An Toan Lao DQng tie'u bang Texas
lai xe hole s6 IDea nhanl
.
.
-
-
t±llf'li~li!i~!!i
-
. .
( jt(]JI!!J:5)!:jj'lJ'l~1\M~ll<!l!IABl- ll1ill'l.£1i!'l • rol!JEIJ\H'!t-fC®ili
.
.,
.
. -
Seguro Social.) I Toi chl!a he dll<fc cap b~ng lai xe cua Te xas/so
ID ca nhan ho~c so An Sinh Xa Hoi.) :tt&=i'l TX ~!ltftll~?.iJ!~filljl
OO.AmlH!f51!1fillj~f±ll'ti'~iJ!~fillj
•
Cit ill!!!G WJ
Female _g)
Social Security No. [last 4 dig its required if you do not have a driver's license or 1.0. number) NUmero de
Segura Social. (Si no tienc liccnda de condu cir ni ldentificad6n pe rsonal, se requiere los Ultimos 4 nUmeros de
su seguro social) SO An Sinh X3 HQi {4 sO cuOi cU a sO An Sinh xa HOi c'an phai cO neu quy vi kh6ng c6 sO b~ng
TX Driver's Lice nse No. or Personal I.D. No. (Issued by TX DPS) NUmero de
su licencia de conduc ir de Texas ode su Cedula de ldentidad expedida par
TO BE COMPLETE,D BY THE ELECTION JUDGE
Ngly Bau
nac imie nto: mes, dia, aiio)(Ngay thang n:im sanh:
ili!E B l1Jj : FJ · B · lJO
Thong, Ngav, Nam)
Precjtt No. where voted
1£
NUm. de Precinto-lugar de votaci6n/Ph.3n Khu noi
<;JN, ll!l'l!lil'.i!\5
q
HomePCT
PCT
CERT/VUID
Vater Registrar Use ONLY
PCT
da sau Cil 56/llHTI:i~hi
I r
Precinct No. whe re registered-------=NUm. de Preclnto-inscrito para votar/Phan Khu nO'i di'i ghi danh sO/ill~
Cf
!ii'i<J1. :lHi'.lltl!l'i
Type of Election Tipa de Elecci6n
Hinh Th.:re Bau cit illlfl~i\1
FOR STATUS:
Authority Conducting Elect ion Autoridad Administronda Ia Elecci6n
Ccr Quan Tnam Quyen Ti{n Hlmh Bliu c<i £%fffl81tr!Pf
BALLOT CODE:
L~
~ _Q !121 0
the fallowing conc/usian(s) was made:
I
j .b
(Write in the Ballot Code, it is f ound on the Provisional Ballot Stub above the
1.
election day.
1.
L
DYES
_xrno
2.
3.
4.
5.
Voting after 7:00P.M . due to court order .
2.
3.
4.
s/
election.
7.
8.
9.
Information on file indicating applicant completed a voter reaistration
llllllllllllllllllllllllllllllllll
lllllllllllllllllllll
311491515
Declaraci6n Jurada de Votante Provisional I Ban Chung Th~ Cua Cir Tri T?m Thai I !mB~il~~~-
TO BE COMPLETED BY VOTER: I um a n:gisterell voter of this political subdivision and in the precinct in whic h I'm aucmpting to vote and have not already voted in this election (either in person or by mail). I am u rcsid~:nt of
this political subdivision. have no t been fina ll y convicted of a felony or if a felon, I have comp leted all of my punishment includ ing nny term of inc<~. rccration, pa role, supervision, period of probat ion, or I have been pardoned. I h01vc
not been determined by a fina l judgment of a coun exercising pro bote jurisdiction to be 101ally menta ll y incapacitated or pan ially mento ll y incapacitated without the right to vote. I unde rstand that giving false information under oath
is o misdemeanor, an<.! I understand that it is a felony of the 2nd degree to vote in an ek ction for wh ich I know I am not eligib le.
(PARA QUE EL VOTANTE LO LLENE: Estoy inscrito como votantc en csta subdivisi6n politica yen cl precinto en cua l cstoy intentando u votur y nun no he votndo en esta clccciOn (en persona o par co rrco). Soy rcsidcntc de
csw subd ivisiOn polit icu, no he sido ddinit ivanu:ntc dcc lil rado culpable de un de lito grave o si soy cl auto r de un dcl ito grave, he cumplido toda mi condcna inclusive cl pcriodo de cncarcclamic nto, Ia libcrtad condicion;;d, In libcrtad
supcrvisada, l.:l libertad vigilada, o he sido i n dult<:~do. No me hun detcrminado par un juicio fina l de una co rte de Ia legal izaci6n de un testa mento, scr totalmcntc incapacitado mc ntalmc nt c o pa rcia lmentc inc:tpoci tado sin cl dcrccho de
vo tar. En tie ndo que da r informac i6n fn lsn bajo juramenta cs un dcli to mcnor y tnmbiCn cnt icndo que cs un de lito grave de 2do grado vola r en una elccci6n s:tbicndo que no cump lo co n los requis it es ncccsD.rios.) (DU"QC HOAN TA:r
86'1 Cll" TRI: T6 i lil cU tri dii ghi Jn nh b6 phiCu li!i phlln khu chinh tri dja phucmg nily v3 trong phiin khu n"ci t6 i cOy djn h bO phi~u va chua b6 ph it u tro ng cu{lc b5u clr nOy (k~ d dich thfl n b6 phiEu hay b6 phi~u b~ng thu). TOi ctr
ngv t ~i ph:in khu chinh trj dia phuong nay, tOi ho3n toa n kh6ng bi kCttn;mg t¢i ho~c nCu 13 nguOi ph(_un t ron~ tQi. t6i d5 ho:'tn th;lnh h~t moi hinh ph~t. baa g6m thOi h;.ln tU. On tree, qll:i n chC, thOi kY thlr th:kh, ho~c d3 duQc.: tha. Phtl.n
quy~t cu6 i cling elm t6a Dn kh6ng tuyCn b6 n1ng 16i 1;1 nguOi m5t hoim toim n:lng lvc v~ m~t tam th<\n hay mtit m¢1 ph;1 n ntlng lvc dC t6 i c.:O quyb dl!Q"C bO phieu. T6i hiCu r~ng khai m:tn khi luyCn th¢ sC bi ph~ m khi nh t¢i, v:lt6i hi~u
r;\ng niu bo phi1u trong m<)t cu<)c b5u cu rna t6i bii t Ia minh khong h<) i dcoditu kiin. tui sc bi coi Ia ph~m tr~ng t<)i dr d¢ 2.) Eflil!I:I'Ji'!:\il: ot;:;\.~uti&iiit/il!l;i"':<':@itil!ti::, ot;:;\.H:Q'!ii'i£l.r.ll*1f!lt*il!!ll'l'lll:l!ii (mF-llltillr.'*
!<l:l'li) • ot;:;\.P\tci&iiifJ!o)J;Z~t~; · liE*fl]l8~!1imlffJ]i!!i!l~!l!lE!Jf1 · iiiZ~II!ie*!m'IHfl:'ll1 · !QpJi*Ji!!;)<l · E!Ji5\l.iJi'~ · llflRI · \l.i'lif
·WJfiJ~E'.Iil~'l\S:Jl~BI!IMt~
ot;:;\.flE!Il!§:"'1!i:l-1ff!FF'!'fi1ilRP\f!l!ml · :MITIW1f"Jlt.fli381-i;f'i3ff~8\Jfillili."F:(filllil<folli~P>.=mlU~ •
last Na me (Apellidol (Hoi
First Name INombreiiTenl (:f.)
• $;\.t't;fdEiill'lil~'l!itiflH1~%~JEfl]ffl1t!JJo:3':lltftl\liliQ
;l(lilj:t.Jilii~llil'litlll·
Name (If any) (Seg un do nombre (si tiene)
dem (neu co) <PIHI:fo ( :G':f;f)
Name (Nombre a nterior)
cO) (fl!/ll:fo)
Res id ence Address: Street Ad dress a nd Apartme nt Num ber, City, State, and ZIP. If none, describe where you live (Do not include PO Box, Rural Rt. or bus iness ad dress) (Domicilio: ca lle y nU mero de a partamento, Ciudad, Estado, y
C6digo Postal: A falta de estes datos, describa Ia local idad de su residencia. {N o ind uya el apartado de correos, camin o rura l, ni direcd6n comercia l.J) {Oja chi ell trU: Ten dLtiJng vel s6 Phbng, Th anh Ph6, Tieu Bang, va Mii B11u Oien.
Neu kh6ng co, ,;n die n ta nai quy vi w ngu (Kh6ng d<I(Ic de dja chi Hop Th <I, Oja Chi O<Ia ng lang hol e Oja Chi Th<Jcmg Mail I ~(flt!!l:!l: : rti:foltHII:ffii~li!'JJI · i)i · Hlffi!f!l!l!l'~,.~ • !tn!f!i!i.'f;f • if~"f'.lllali'!ll®(flt!!!\5 ( ~'l o/J!flillll
I§J(l1!l'MR!i'!j ·
l<llmM.~;l',lili~ifii'lltJJillu:)
Mailing Address: City, Sta te, and ZIP. If mail ca nnot be delive red to your res id ence address.
postal:
Ciudad, Estado y C6digo Postal, si no es posi ble e ntreg arle corres ponde ncia en su domicilio). (Oja Chi Glti Thll:
Thanh PhO, Tieu Bang, va Ma Bllu oi e n. N€u khOng the chuyfn t hlf t&l dja chi ctr ng v cUa quy vi.) ~¥.t.tllit.ll:: : i1J ,
J·IWl!E~i!RiilliW<
• II!HI![q:i*~;;~<i2Sill!,T:R'J/6{llJill:!l: •
Male D
(Hombre)(Nam)(!IJ)
appropriate boJt: Marque d
cu:ldro apro piado: 8:inh d5u vilo 0
thic h hQ'P
1£mttt:hTill;>q i~J""
:
TX Drive r's lice nse No. or Personal I. D. No. (Issued by TX OPS) NUmero de
su licencia de conducir de Texas ode su c edu la de lde ntidad ex pedida por
el Departame nto de Seguri dad Publ ica de Tex as ). 50 sang Loi i Xe cUa tieu
I
FemaleK
(M ujcr)( N~)(:Y;)
Social Se cu rity No. (last 4 digits required if you do not have a drive r's license or I. D.
Segura Social. (Sino tiene lice ncia de con ducir ni identificaci6 n pe rsona l, se req uie re los Ultimos 4 nUmeros de
c6 neu quy vi kh6ng c6 sO bang
su seguro social) 50 An Sin h xa HO i (4 sO cuOi cUa sO An Si nh xa HQi c"5n
I
ARE YOU A UNITED
STATES CITIZEN?
(i,SOY CIU DADANO/A DE LOS
ESTADOS UNIDOS'!) (QUY V!
C6 PH AI LA C6NG DAN HOA
KY KH6NG?) !J!!JQ!X!~~~n.!E?
~es
D
No
CSi)(Co)(~)
HomePCT
County Clerk Use DNL Y
CERT/VUIO
VDbZ .-:
Precinct No. w here voted
NUm . de Precin to-l ugar de votad6n/Ph.3n Khu nai da B"J u CU 50/}jj'~~ti
M.tltl'liliM\1
ll- 5"- \3
Precinct No. w here registe red
PCT
PCT
OD0r
NUm . de Preclnto-ins crito pa ra vota r/P h.3 n Khu nO'i da ghl dan h sO/}E~
!r.>l!.'l!Wit~
·Hinh Th~c Bau ctl il.l!t'!l:ll!tl
C<1 Quan Tham Quyen Ti€n Hllnh
FOR STATUS:
Bliu Co/ .ERJ.!f!flflfJtlf
~&v-~
I, the voter registrar/ deputy registrar, did research the records of my office and
the follo wing conclusion(s) was made:
BALLOT CODE:
2
o :)5 _?--j
l 03
(Writ e in t he Ball ot Code, it is f ou nd on t he Provis ional Ballot Stub above t he
voter's signat ure area . The Provisi onal Ballot St ub is ge nerat ed from the JBc.)
FOR VOTERS WHO DID NOT PRESENT ACCEPTABLE PHOTO /DEN T/FICA TION
AT THE POLLING PLA CE
1.
election da y.
D YES
l.i_
D NO
Failed to present acceptabl e form of identificat ion or voter
ce rtificate with exemption .
2.
3.
Vater executed religious objection affidavit within 6 days of election day.
4.
Voter executed natural disaster affidavit within 6 da ys of election da y.
5.
V
categories 1·4 above, within 6 days of election do y.
2.
Voter not on list of reg istered voters .
3.
Voter not on list, registered in anothe r precinct.
4.
5.
Voting after 7:00P .M. due t o court order.
FOR VOTERS WHO VOTED PROVISIONAL! Y FOR OTHER REASONS
6.
election.
7.
B.
Registered to vote in o diffe rent precinct within the county.
·,
'
- - - - - -- - - - -
TO BE COMPLETED 8\' VOTER: I am a registered voter of this political subdivision and in the precinct in which I'm attempting to vote and have not already voted in thi~ election {either in person or by mail). I am a resident of
this political subdivision, have not been finally convicted of a felony or if a felon , I have completed all of my punishment including, uny term of incarceration, parole, supervision. period of probation, or 1 have been pan.Junctl. I have:
not been determined by a final judgment of a coun exercising probate jurisdiction to be totally mentally incapacitated or partially mentally incapacitated without the right to vote. I understand that giving false information under oath
is a misrlemcanor, and I understand that it is a felony of the 2nd ctegrcc to vote in an elec tion for which I know I am not eligib le.
(PARA QUE [L VOTANTE LO LLENE: Estoy inscrito como votantc en csta subdivisiOn politiea yen c l prceinto en eual estoy intentando a volar y aun no he votado en estil clccci6n (en persona o par eorrco). Soyrcs idcnte de
cs ta subdiv isiOn polftica, no he sido dcfinitivamcntc declarado culpable de un delito gn.Jve o si soy cl autor de un dclito b'f:lve. he cumplido toda mi condcna inclus ive cl periodo de cncu rcc lamiento, la libcrtad condieional,la libcr1 ad
supervisoda, lo libcrtad vigilada, o he sido indultndo. No me hun dcte rminado por un juicio fino! de una cone de Ia lcgulizuci6n de un testamento, scr totolmcntc incnpucitodo rncntalmcntc o pnrcialmcnte ineapacitodo si n c1 dcrccho de
vo lar. Enticndo que dar infonnaci6n fals;~ bajo juramenta cs un dclito mcnor y tambiCn cnticndo que cs un delito grave de 2do grado votar en uno clccci6n sabic ndo que no cump lo con los requisites neccsarios.) (OU'QC HOAN l'AT
B01 Ct} TRI: T6i Iii cir tri t.J;j ghi d:mh b6 phieu tyi ph:in khu chinh tri t.ljt~ phucmg na y vil trung phtt n khu rna tOi cOy djnh bO phi~u vil chlf"d b6 phi~u trong cu()c b~u clr mly (k~ d dich thiin bO phi~u huy bO phi~u b~ng thu) . TOi cu
ngv lili phan khu ehinh tri dja phuong nay. t6i hoan to3n kh6ng bj k~t trQng tQi ho~c n6u Iii nguOi ph~m trong tQi, t6i d!l ho6n th;ln h h6t mQi hinh ph{lt. bao gbm thbi h;m tU , iln trco. quiin ch~. thOi kY thl1th3ch, ho~c d!l duo-c tha. Ph3n
quy~t cul> i eU.ng cUo tOa :in kh6ng tuyCn hil rAng 1i1i Iii ngu<'ri mAt hoi:m toiin n:lng h.rc v~ m~t tllm th5n ha y m~t m(lt ph&n nDng h,rc d6 t6i c6 quy~n dU"Qe bO phi~u . T6i hi~u r~ng kh::~i man khi tu yCn th¢ sC bj ph~m khinh 1(1 i, vj tOi hi~u
r~ng n~u b6 phi~u trong mc,lt cuOc b5u clr m:i t6i bi~tl:i minh kh6ng hOi dU di~ u lci~n. t6i sC bj coi 1:1 ph11m trqng tQi dp dQ 2.) EHill~!i{~: ~A~Jltif9:;{5fS~p;jz.g.;i;m~. ~A.fi:t!~..Elrf.j*tfut:;::UHfl~ni~ (i:Qgj~!li~~t
Jl!~;~) • ::4<A1.0Jitl!UE:t:li~Z/.5~ · r.E*f,I;!Jil'f!f!fi11liliHJ<QI~:iE~o · ;re~llfHHI?.l'f!f!lW · @ffil'fl!\li11 · @fili!!iiJi'; · ~RI · !iii'lll' · !:Jlif'JJ';JE'Jfl:l'i:'lt -!f!;reE.Jthi'<~
~<if61Jffli!R\Ill:i\'HIE • >tARJlJih!:Jr1oHt:lf.H*'F'l'I'i!ioRlM!i!~~ · :lti7~m•JJ~!36Hl~'i!il~fi'Jtl!/;1/.Tifil!!ll'Pill:iWlll=i&lflgjl·
fi<St Name (Nombre) (Ten) (og)
Last Name (Apellido) (Ho) (II£)
• *Ar.E*i&il1'1l!!JOffi;;';/fH1l~!ll::iE~f~Jlll'lt~;reruHli~
en dem (neu c6)
'f'r·1~
(Ten cO) ('ljf!l:g)
( ;fil'f I
Alli7lfo!Vy
Residence Address: Street Address and Apartment Number, City, State, and ZIP. If none, describe where you live (Do not include PO Box, Rural Rt . or business address) (Domicil io: catle y nUmero de apartamento, Ciudad, Estado, y
COdlgo Postal: A falta de estos datos, describa Ia localidad de su residencia. (No induya el apartado de correos, camino rural, ni direcci6n comercial.)) (Dia chi w trU: Ten dl!Cmg va sO PhOng, Thanh Ph6, Tie u Bang, va Ma Bvu Oien.
Neu khong c6, xin dien tj nc:li quyvj w ng~ (Khong ducrc de dja chi Hiip Thu, Oja Ch( Oucng Lang ho~c Oja Chi Thuang Mail) /.5{1Jtl!Jll: : l!J:glfulll:f{J01J!'lif! · i/i · iii f{J~Ijl~l;!l;'iJR • j!(]J.I!;)Il'[ · Wo1'WJ~RJl@{±ltM\I; ( i1i1>JI!Jffill
:J.r. #=;
/;<.!'? w£LtYi. . .
c2.
fol(>iffi'll!~ · :'<119H!&~:f.fili~ifli,Rifuttl
Mailing Address: City, State, and ZIP. If mail cannot be delive red to your residence address. (Direcci6n postal:
Cludad, Estado y C6digo Postal, si noes posible entregarlc correspondencia en su domicilio). (Dja Chi Glti Thll:
Thanh Ph6, Tieu Bang, va Ma BU'u men . N€u kh6ng the' chuye'n thl.l' t&i dja chi cu ngv cUa quy vj.J ~~t~fJJ: : ffi ·
IHfllWBi!tllli~ • !zD!llillll\lt!!\\i;t;i.ilii!t:ll'Jf.Sf±Jfulll: •
Gender: (Optional] (Sexo (Optativo)) Gloi tlnh:(Khong
bat buoc tHU: <CJJ1l~'Ftro
Thang, Ngly, Nam) W~BWl: FJ · B · fF
Male~- Female 0
(Hombre)(Nam)(!tj)
cuadro apropiado: E>:inh d5 u vtlo 0
1hich hqp i£®1lt7Jn!F'lill'I1:J :
TX Driver's license No. or Personal J.D. No. {Issued by TX DPS} NUmero de
su lice ncia de conducir de Texas ode su Cfdula de ldentidad cxpedida par
cl Departamento de Seguridad Publica de Texas). 56 B~ng lfli Xe cUa tit~u
nacimiento: mes, dfa, aiio)(Ng3y thflng nam sanh:
(Mujcr)( NG)i:il:)
Social Security No. (last 4 digits requ ired if you do not have a driver's license or 1.0. number) NUmero de
Segura Social. (Si no tlene licencia de conducir ni identificaci6n personal, se requiere los Ultimos 4 nUmeros de
su seguro social) 56 An Sinh Xil HOi (4 sO cuOi cUa sO An Sinh Xil HQi dn phili c6 n€u quy vj kh6ng c6 sO bans:
•
•
::J
li
I
i!_ •'
:,.
~f
ARE YOU A UNITED
STATES CITIZEN?
ESTADOS UNIDOS'>) (QUY VI
c6 PHAI LA CONG DAN HOA
KY KHONG?J !.l!:lHHilil~Ei';P!!\7
- /
lk:!Y'es
D No
lSi)( C6)(~)
(No)(Khong)(i'l)
0
: . t . . .• .
. •
.• .
.
• . •.
•
!j,•
..
1 have not been issued a TX driver's license/
Texas/Cedula de ldentidad personal de Texas ni un Numero de
Segura S_ocial.[ { T§i chll~ he ~lfQ'_c cap ?ang lai xe cua Tex~s/s6
ID ca nhan ho~c so An S1nh Xa Ho1.) 1Ji:;)1_~ TX )l'i:~"fM.!i!5!'1iilll/
@.J\!gfl1~5!'1iilll~U~:!i:~~D!!l
•
X
Hom~
PCT
PCT
Date of Election Fecha de fa E/ecci6n
NgOy Bau Cit il!!ll B WJ
D0.31-
I8
PCT
4/tJA/,J;"
NUm. de Precinto-inscrlto para votar/Phan Khu nai dii ghi danh
Ob-:37
si5/ll!~
!i'lll. :lfg[',Jfu!!!l;
Type of Election npo de Elecci6n
Authority Conducting Elect ion Autoridod Administrondo Ia E/eccidn
Hinh Th\tc Bl u ell il!!ll.l!li~
Cr1 Quan Th6m Quyen Tien Hl>nh Bou Cv .Tf.Jil!lift!lliJJ
FOR STATUS:
BALLOT CODE:
ZLf
'!!)§:$~- ___ _
(Write in the Ballot Code, it is found on the Provi~al Ballot Stub above the
1.
election doy.
D YES
1.
D NO
2.
3.
4.
5.
2.
3.
4.
5.
6.Y:
.Not a registered vot~r or reflistration not effective in time for this
election.
~· fo'll'f-:ti ~~
cancelled ma il ballot application.
7.
Vot ing afte r 7:00P.M. due to court order.
B.
9.
Information on file indicatina aoolicant com ole ted a voter reaistration
• .• I
PR
JJIJJJIIJJJJIJJIJJJJIJJJJJ JJJ JJJJJJIJIJJJJJJIIJIIJ/IJJ/
311558016
.
·
~
Declaracion Jurada de Votante Provisional I Bim Ch'(rng Th~ Cua Cu Tri T~m Thai I lm~ll
"'. ,JaW:
TO BE COMPLETED BY VOTER: I nm a registered voter of this politicnl subdiv ision and in the prec inct in which I'm aucmpting to vote and have not already vo ted in this election (e ither in person or by mai l). 1 am n reside nt of
this political subdi vision, have not been fin<:~ ll y convicted of a fdony or if o. felon, I have comp leted all of my punishment including any term of incarceration, paro le, supervisio n. period or probation, or I ha ve been pardoned. I ha ve
no t been llctcnnined by a fin<.~ I judgment of a cour1 exercisi ng probate jurisdic tio n to be totally mtnta ll y incapac itated or part ia lly mentall y im:apon;itah:J wit hout the right to vote. I umlt:rstand that giving fa lse informa tion und er oath
is a misdemeanor, and I under$tnnd that it is a felony of t he 2nd degree to vote in an elect ion for which I know I am not e lig ible.
(PARA QUE EL VOTANTE LO LLENE: Estoy inscrito como votantc en est a subd ivisiOn politic a yen c l prccinto en cual cstoy intcntando a votary aun no he votado en esta elecci6n (en persona o por correo). Soy rcsidente de
est a subdivisi6n pol it ica. no he sido dcfinitivamcntc dcclarodo cu lpabl e de un de lito gmvc o si soy cl au tor de un de lit o t,rravc, he cump lido toda mi co nd e no. inclusive d pcr iodo de cncarcclamic nto, 1a Iibert ad co ndiciona l. Ia libcrtad
supervisadtl, Ia libertad vigi lada , o he ~ id o indultado. No me han dcterminado por un juicio !inal de una CO rl e de Ia lcga li znci(m de un testamento, scr towlmcnte incapac itad o mentalmcntc o parc ialmcntc incapacitado si n cl dcrccho de
vo~ar. E_nti cndo que dar informaciOn fa lsn bajo juramenta cs un de lit o mcnor y tarnbiCn cnticndo que cs un deli to grave de 2do grado vota r en una elecci6n sab iend~ que no cun~plo con ·los requ isites neccsarios.), (O':J"QC HOAN TAT
BOI cu· TRI: T6i ta clr tri dil ghi danh b6 phiCu t;;ti ph5n khu chinh trj d ja phucrng n:ly va trong phfl. n khu m:i t6i c6 ydj nh b6 phiCu vii. chua b6 phiCu trong cu9c b:l u clr n:\y (kC cia dich thtin b6 phiCu hay b6 phit u b~ng thu). T6i cv
ngv liJi ph5.n khu chinh tri djn phuong nily, t6i ho<ln to:in kh6ng bj k~t trong t9i ho~c n~u Iii ngu&i ph~m trQn~ t¢i, t6 i dil ho:in th.lnh ht t mqi hinh ph(,'t, bao gbm th&i h;:m tU, iln \reo, quiln ch6, th&i k)' thlr th:kh, ho~c dil dVQ'l: tho. PhOn
quyft cu6 i dmg ella tOa <in kh6ng tuyCn b6 r~ng t6i l<l nguOi mjt ho<ln to ii. n nilng h,rc v~ m~tt;lm th~n huy m:it rn{l t ph~n nilng h,1c d~ t6i cO quy~n du<,Jc bO phi~ u . TOi hi~u r~nt: khai man khi tuyCn th~ sC bi ph1,1rn khinh tQi, va t6i hi~u
r~ng IH~u b6 phitutrong m9t cu(lc b5u ciJ m~ t6i bi~tll\ minh kh6ng h{li dU di~u ki~n, tlii sC hi coi 13 ph\Jm trong t¢i dr d(l2.) dJ U!~!.ilf.i{: :.:t.:AAJltif::t{;f:ifa~fAJ.L.g-;~m~. ~AN%!~.§.fi!;j*:(fJtt;Xillffi4'Ht;w (f;QI3~Y!~m:
!Jl:Wll • :<$:,A.]!,)IltiJJU51:!i!;ll;Z/iSI.'\'; · l:t*fi!lllfi<H!HilmiMili<i¥JEij)l · ~ant~llim1'i!IUJl · @~111'i!ai'iin · @!2i~i;1/; · ~~~f.l · Wii'il' · t~II'Jl'J81!1~5'\:·!l!ll<81/liili!e • :<1>:A.r.t*'i/li ilJ~l>i1ltiC!i!ltl~'f'bl:JEiml'll'~:ii:3':~ffill7lt~
!!i:lit:!Jilii!!1\!lll\'<t~
• :<1>:ADJIHJ7.:EGtJti!I!1!FH'n'W\~tl!!Jll · ~ 714t£ 1Jil~l32:ff.f~ti~IY'Jt.li~'CFifil!!i!'i' !l!\W];)=!JlifH!l •
First Name [Nombre) (Ten)(~)
Last Name {Apellido) [Hoi (1/t)
[Tencu)(!Jll!l:l5l
Middle Name (if any} (Segun do nombre {si tiene )
en dem (neu c6) <Pra9~ ( '6'~)
Residence Address: Street Address and Apartment Number, City, State, and ZIP. 1f none, describe where you live (Do not include PO Box, Rural Rt. or business address) (Domicilio: caHe y nUmero de apartamento, Ciudad, Estado, y
C6digo Posta l: A falta de estes datos, describa Ia localidad de su residencia. (No incluya el apartado de correos, cami no rur al, ni direcci6n comercial.)) (Dja chi ell trU : TCn dl!Ong va sO PhOng, Thanh Ph6, neu Bang, vc\ Ma Blfu oien.
Neu khilng c6, xin dien ta nai quy vi cLt ngv {K hilng dLtqc de d)a chi Hi)p ThLt, Oia Chi OLtiYng lang ho~c O)a Chi ThLtang Moil I ~{±J~JJ!: : !)ji',l~lli:T!l07.illl'l · 111 · ilH!l!W<li'llh'lR • JmffiilHl' • ~~~Wlff!IB.Jl@f±JU\ ( 51/o/Jmffir,
).;f1iiUVilli ·
~~~·~~~~~!J!: )
A-\ leV\ 'f)
~'d"b 18--
Mailing Address: City, State, and ZIP. If mai l cannot be del ivere d to your resi ence address. (Oirecci6n postal:
Ciudad, Estado y C6digo Postal, si noes posib le entregarle correspondencia en su domicilio). (Dja Chl Glri Thll:
Thanh Ph6, Ti~u Bang, va Ma Bvu Oien. Neu khilng th ~ chuy~n thv tai dia chi cv ngv cua quy v[.) Jil"li'J~IJ!: :
Gender: (Optional) (Sexo (Optative) ) Gi&i tinh :(K hOng
V:~male D
m•
lHfOJI!i!RIE;'lR • ~~!<ll~l!ttitiili~!J:IY'J~I±Il!'.!J!: •
bit b : : : :
(Hombre)[Nom)(!}j)
Check appropria te box: Marque cl
cuadru upropiallo: Oilnh ddu vcio 6
lhich h(l]> t£ii1JJB;Jj~P'Jill1Jt) :
su llcencia de conduc ir de Texas ode su Cedula de ldentidad e~epedida por
el Departamento de Seguridad Publica de Texas). sO B.!ing L3 i Xe cUa t ieu
bang Texas ho~c sO ID ca nhan (do BQ An To.iln Lao OQng tieu bang Texas
Date of Birth: Month, Day, Year (Fec ha de
nacim iento: mes , dia , ai'lo){Ngily thang nam sa nh :
Thang, Ngay, Nam) :±J~ B Wl : F! · B · ~
(Mujcr)( Nu)(j{)
Social Security No. {last 4 d ig its required if you do not have a driver's license or 1.0. number) NUmero de
Segura Social. (Sino tiene licencia de conducir ni identificaci6n persona l, se requlere los Ultimos 4 nUme ros de
su seguro soci<ll} SO An Sinh xa HQi (4 sO cuOi cUa sO An Sinh xa HOi din phai cO n€u quy vi kh6ng cO sO b~ng
lai xe hooc solD ca nhan)
UI\Hi'~'i1Jf6!!i ( ~JlHJ:;.I!~lli!l!ftll~.l;liltl!llA.m-17li<1!'<'!6!!i · ffi!JiHM±'ti'-FlilH$:
ARE YOU A UNITED
STATES CITIZEN?
(j,SOY CIUDADANO/A DE LOS
ESTADOS UN IDOS?) (QUY V I
KY
lv:~ !m~~::%?
(Si)(C6)(Jil.)
(No)(Khilng)(i"'f)
. .
~·~~
Texas/ Cedilla de identidad personal de Te xas ni un Numero de
Segura Social.) ( To i chLta he dLtqc cap b~ng lai xe cua Texas/so
ID ca nhan ho~c s6 An Sinh Xa Hi)i.) ili;).\l:1'J TX :lll:!~~!l.lillii1U!!li
1lJJ,.J}f)Hilii1U!!l!iiGU~'fi:'~MU!!l
•
..
..
.
.. .
....
X
Date of Election Fecha de Ia flecciOn
Ngay Bau C(J il!!i! El Wl
. . .
HomePCT
Per
CERT/VUID
Per
Ntim. de Precinto-lu gar de votaci6n/Phan Khu nal d:i B"au Clt 5 6/.iB~t:.;
~'2....
'lf!./l!\Vlltll!\l
Precinct No. where registered ------=
_.)'--....,NUm . de Precinto· ln scrlto para votar/Phan Khu nai
!>1911.
Type of Ele ct ion Tipo de Eleccidn
Hlnh Thlic B~u c(J il!lfll:fim
da ghi danh sO/mm;
:!Hcl~!\l
FOR STATUS:
Au thority Conducting Elect ion Autoridod Administrando Ia Elcccidn
Ca Quon ThOrn Quyen Ti{n HOnh Biiu cV .:EM.ii!Ht/1/N
I. the voter registrar/deputy registrar, did research the records of my office and
the following conc/usion(s) was made: ·
1.
election day.
0 YES
1.
t/
(B"'N 0
L-A
3.
5.
n
3.
Voter executed religious objection affidavit within 6 days of election doy.
4.
S.
V
categories 1·4 above, within 6 doys of election day.
'J v..c,t}- Mov.tt\'
2.
4.
'~c.e"'c;-e.
2.
6.
election.
7.
8.
9.
Information on file indicating applicant completed o voter registration
.··. \
;

Case 2:13-cv-00193 Document 737-5 Filed in TXSD on 11/17/14

Transcripción

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