In the State of Illinois )

                                     )

County of

)

AFFIDAVIT

I, the undersigned Affiant, do hereby state under penalty of perjury that I have personal knowledge of the
matters stated herein and that if called to testify I would state the same.

1. My name is 

I Reside at

, Illinois

2. I am (Check one) 

of Township/Ward

3. On

, I was present

, the voting center for

in

located at

in

, Illinois

4. At the above time and place, the following occurred (fill out all that apply):

a. The voting center was not open for

until

and

, from approximately

I was unable to vote because the voting center was not open and I could not wait for the following reason

b. The Election Judge(s) would not allow me to vote because: 

c. I witnessed someone outwardly supporting a candidate or political party within 100 feet of the voting center. Specifically, I witnessed the following:

d. I witnessed (fill in)

FURTHER AFFIANT SAYETH NOT

VERIFICATION

Under penalties as provided by the law pursuant to Section 1-109 of Illinois Code of Civil  Procedure, the undersigned certifies that the statements set forth in this instrument are true and correct, except  as to matters therein stated to be information and belief, and as to such matters the undersigned certifies as  aforesaid that he/she verily believes the same to be true. 

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