Minn. R. agency 133, ch. 8200, FORMS, pt. 8200.9960 - CHALLENGES TO VOTER REGISTRATION, FORM TO BE USED UNDER MINNESOTA STATUTES, SECTION 204C.12, SUBDIVISION 2

I,_____, do hereby state under oath,
Name of person making challenge
I am:
() an election judge.
() a challenger authorized by Minnesota Statutes, section 204C.07.
() a Minnesota voter.
I reside at_____,_____,
	Street Address	City or Township
Telephone number:_____
E-mail address (optional):_____
I challenge the registration of _____
		Name of challenged voter
whose registration lists his or her residence as
_____		_____
	Street Address	City or Township
This challenge is based on my personal knowledge. The grounds for my challenge are:_____
_____
_____
(attach additional sheets of signed statement if necessary).
I swear or affirm that the information stated here is truthful.
__/__/____	_____
Date	Signature of Challenger
Signed and sworn to or affirmed before me
__/__/____	_____
Date	Signature of Election Judge
For Election Judge Use Only:
Challenge was administered by Election Judge:_____
Time:_____
() Voter refused to take challenge oath.
() Challenge was dismissed: Voter passed challenge and voted.
() Challenge was sustained: Voter failed challenge and did not vote.
Additional Comments:

Notes

Minn. R. agency 133, ch. 8200, FORMS, pt. 8200.9960

32 SR 2055

Statutory Authority: MS s 201.061; 201.221; 203B.09