South Dakota Administrative Rules
Title 5 - Secretary of State
Article 5:02 - State Board of Elections
Chapter 5:02:05 - Forms for conduct of elections
Section 5:02:05:22 - Provisional ballot envelope

The provisional ballot envelope shall be blue and in the following form:

Voter's Affirmation for a Provisional Ballot

My voter registration was completed on or about the following date and was left with the following person or agency for delivery to the county auditor: ____________________________

__________________________________________________________________________. My name is _________________________, I reside at ____________________________, my mailing address is _______________________________, my date of birth is ___________, my South Dakota driver license number is ___________, my daytime telephone number is ___________ and my evening telephone number is ___________. If I do not have a South Dakota driver license the last four digits of my social security number are ______.

I understand if the election authority determines that I am not registered in this precinct and therefore not eligible to vote in this precinct, my vote will not be counted. I further understand that my vote may not be secret if only one provisional ballot is cast in the precinct. I declare and affirm under penalty of perjury that I registered and am eligible to vote in this precinct.

________________________________________ ___________________

Signature of Voter Date

To be completed by a precinct election worker:

Precinct number _____________ Type of ballot provided to voter ______________

__________________________________

Signature of precinct worker

General Authority: SDCL 12-18-40.

Law Implemented: SDCL 12-18-40.