REQUEST

FOR APPOINTMENT OF A CERTIFIED ELECTION MONITOR

STATE OF ARKANSAS

COUNTY OF ___

I, ____, the undersigned, hereby request that a monitor be sent to observe the administration of the election to be held on the day of __ in ___ County, Arkansas for the following reasons (attach additional sheets if needed and enclose any supporting documentation or relevant evidence):

DECLARATION

I, ____, hereby declare under penalty of perjury this day of __ that the foregoing statements, comments, and information contained herein are true and correct to the best of my knowledge.

Signature of Requestor: _______

Home Address: ____ Day Phone: ______ (Street, City, State, Zip)

Remit to: State Board of Election Commissioners 501 Woodlane, Suite 401N Little Rock, Arkansas 72201 (501) 682-1834 (800) 411-6996