6.80
6.80
Mechanics of voting. 6.80(1)(1)
Voting booth or machine use. Only one individual at a time is permitted to occupy a voting booth or machine, except that an elector who is a parent or guardian may be accompanied by the elector's minor child or minor ward, and an elector who qualifies for assistance under
s. 6.82 (2) may be assisted as provided in that subsection.
6.80(2)(a)(a) Upon receiving his or her ballot and without leaving the polling place, the elector shall enter an unoccupied voting booth or machine alone to cast his or her vote, except as authorized in
sub. (1). An elector may use or copy an unofficial sample ballot which may be marked in advance of entering the polling place, but an elector may not use or bring into the polling place any ballot printed upon paper of the type required or utilized for official ballots at that polling place.
6.80(2)(am)
(am) In partisan primaries, an elector may vote for a person as the candidate of the party of the elector's choice, if that person's name does not appear on the official ballot of that party, by writing in the name of the person in the space provided on the ballot or the ballot provided for that purpose, or where voting machines are used, in the irregular ballot device, designating the party for which the elector desires such person to be the nominee.
6.80(2)(b)
(b) After preparing his or her ballot, unless the ballot is intended for counting with automatic tabulating equipment, the elector shall fold it so its face will be concealed.
6.80(2)(c)
(c) Any elector who, by accident or mistake, spoils or erroneously prepares a ballot may receive another, by returning the defective ballot, but not to exceed 3 ballots in all.
6.80(2)(d)
(d) If an elector receives a ballot which is not initialed by 2 inspectors, or is defective in any other way, the elector shall return it to the inspectors. If the initials are missing, the inspectors shall supply the missing initials. If the ballot is defective, they shall destroy it and issue another ballot to the elector.
6.80(2)(e)
(e) Upon voting his or her ballot, the elector shall publicly and in person deposit it into the ballot box or deliver it to an inspector, who shall deposit the ballot into the ballot box.
6.80(2)(f)
(f) In the presidential preference primary and other partisan primary elections at polling places where ballots are distributed to electors, unless the ballots are prepared under
s. 5.655 or are utilized with an electronic voting system in which all candidates appear on the same ballot, after the elector prepares his or her ballot the elector shall detach the remaining ballots, fold the ballots to be discarded and fold the completed ballot unless the ballot is intended for counting with automatic tabulating equipment. The elector shall then either personally deposit the ballots to be discarded into the separate ballot box marked "blank ballot box" and deposit the completed ballot into the ballot box indicated by the inspectors, or give the ballots to an inspector who shall deposit the ballots directly into the appropriate ballot boxes. The inspectors shall keep the blank ballot box locked until the canvass is completed and shall dispose of the blank ballots as prescribed by the municipal clerk.
6.80(3)
(3) Time in booth or machine. 6.80(3)(a)(a) Each elector shall be allowed a reasonable time to vote. Unless otherwise specified for that election, a majority of the inspectors shall determine the time each elector shall have to mark the ballot, taking into consideration the size of the ballot and the number of electors in line waiting to vote. In no case shall the time be less than one minute. If there are electors in line waiting to vote, the time shall not exceed 5 minutes.
6.80(3)(b)
(b) If an elector refuses to leave the booth or machine after being notified by one of the inspectors that the time has expired, the elector shall be removed by the inspectors.
6.82
6.82
Assisting electors. 6.82(1)(1)
Receipt of ballot at poll entrance. 6.82(1)(a)(a) When any inspectors are informed that an eligible elector is at the entrance to the polling place who as a result of disability is unable to enter the polling place, they shall permit the elector to be assisted in marking a ballot by any individual selected by the elector, except the elector's employer or an agent of that employer or an officer or agent of a labor organization which represents the elector. Except as authorized in
s. 6.79 (6) and
(7), the individual selected by the elector shall present to the inspectors proof of identification and, if the proof of identification does not constitute proof of residence under
s. 6.34, shall also provide proof of residence under
s. 6.34 for the assisted elector, whenever required, and all other information necessary for the elector to obtain a ballot under
s. 6.79 (2). The inspectors shall verify that the name on the proof of identification presented by the person assisting the elector conforms to the elector's name on the poll list or separate list and shall verify that any photograph appearing on that document reasonably resembles the elector. The inspectors shall then issue a ballot to the individual selected by the elector and shall accompany the individual to the polling place entrance where the assistance is to be given. If the ballot is a paper ballot, the assisting individual shall fold the ballot after the ballot is marked by the assisting individual. The assisting individual shall then immediately take the ballot into the polling place and give the ballot to an inspector. The inspector shall distinctly announce that he or she has "a ballot offered by .... (stating person's name), an elector who, as a result of disability, is unable to enter the polling place without assistance". The inspector shall then ask, "Does anyone object to the reception of this ballot?" If no objection is made, the inspectors shall record the elector's name under
s. 6.79 and deposit the ballot in the ballot box, and shall make a notation on the poll list: "Ballot received at poll entrance".
6.82(1)(b)
(b) If objection to receiving the ballot is made by any qualified elector present, the inspectors shall receive the ballot under
s. 6.95.
6.82(2)(a)(a) If an elector declares to the presiding election official that he or she cannot read or write, or has difficulty in reading, writing or understanding English or that due to disability is unable to mark a ballot or depress a button or lever on a voting machine, the elector shall be informed by the officials that he or she may have assistance. When assistance is requested, the elector may select any individual to assist in casting his or her vote. The selected individual rendering assistance may not be the elector's employer or an agent of that employer or an officer or agent of a labor organization which represents the elector. The selected individual shall certify on the back of the ballot that it was marked with his or her assistance. Where voting machines are used, certification shall be made on the registration list.
6.82(2)(b)
(b) The individual chosen shall enter the voting booth or machine with the elector and shall read the names of all candidates on the ballot for each office, and ask, "For which one do you vote?". The ballot shall be marked or the lever or button depressed according to the elector's expressed preference. The individual selected to assist may not disclose to anyone how the elector voted.
6.82(2)(c)
(c) Intoxication shall not be regarded as a disability.
6.82(2)(d)
(d) The election officials shall enter upon the poll list after the name of any elector who had assistance in voting the word "assisted". The officials shall also record on the poll list the full name and address of the individual who renders assistance.
6.82(3)
(3) Use of paper ballots. Whenever, in a municipality in which voting machines are used, an elector declares to the chief inspector that, due to physical disability, the elector is unable to depress a button or lever on a voting machine, the inspectors shall permit the elector to vote using a paper ballot and voting booth.
6.82(4)
(4) Solicitation prohibited. No election official or other person assisting an elector under this section or
s. 5.79 may request, suggest or seek to persuade an elector to cast a vote for or against any candidate, party or question.
6.82 Annotation
An elector with dyslexia may qualify for voter assistance under sub. (2), [1971 stats.]. 62 Atty. Gen. 195.
VOTING ABSENTEE
6.84(1)(1)
Legislative policy. The legislature finds that voting is a constitutional right, the vigorous exercise of which should be strongly encouraged. In contrast, voting by absentee ballot is a privilege exercised wholly outside the traditional safeguards of the polling place. The legislature finds that the privilege of voting by absentee ballot must be carefully regulated to prevent the potential for fraud or abuse; to prevent overzealous solicitation of absent electors who may prefer not to participate in an election; to prevent undue influence on an absent elector to vote for or against a candidate or to cast a particular vote in a referendum; or other similar abuses.
6.84(2)
(2) Interpretation. Notwithstanding
s. 5.01 (1), with respect to matters relating to the absentee ballot process,
ss. 6.86,
6.87 (3) to
(7) and
9.01 (1) (b) 2. and
4. shall be construed as mandatory. Ballots cast in contravention of the procedures specified in those provisions may not be counted. Ballots counted in contravention of the procedures specified in those provisions may not be included in the certified result of any election.
6.84 History
History: 1985 a. 304;
1987 a. 391.
6.85
6.85
Absent elector; definition. 6.85(1)
(1) An absent elector is any otherwise qualified elector who for any reason is unable or unwilling to appear at the polling place in his or her ward or election district.
6.85(2)
(2) Any otherwise qualified elector who changes residence within this state by moving to a different ward or municipality later than 28 days prior to an election may vote an absentee ballot in the ward or municipality where he or she was qualified to vote before moving.
6.85(3)
(3) An elector qualifying under this section may vote by absentee ballot under
ss. 6.86 to
6.89.
6.85 Annotation
Voter residency and absentee voting is discussed. 60 Atty. Gen. 214.
6.855
6.855
Alternate absentee ballot site. 6.855(1)
(1) The governing body of a municipality may elect to designate a site other than the office of the municipal clerk or board of election commissioners as the location from which electors of the municipality may request and vote absentee ballots and to which voted absentee ballots shall be returned by electors for any election. The designated site shall be located as near as practicable to the office of the municipal clerk or board of election commissioners and no site may be designated that affords an advantage to any political party. An election by a governing body to designate an alternate site under this section shall be made no fewer than 14 days prior to the time that absentee ballots are available for the primary under
s. 7.15 (1) (cm), if a primary is scheduled to be held, or at least 14 days prior to the time that absentee ballots are available for the election under
s. 7.15 (1) (cm), if a primary is not scheduled to be held, and shall remain in effect until at least the day after the election. If the governing body of a municipality makes an election under this section, no function related to voting and return of absentee ballots that is to be conducted at the alternate site may be conducted in the office of the municipal clerk or board of election commissioners.
6.855(2)
(2) The municipal clerk or board of election commissioners shall prominently display a notice of the designation of the alternate site selected under
sub. (1) in the office of the municipal clerk or board of election commissioners beginning on the date that the site is designated under
sub. (1) and continuing through the period that absentee ballots are available for the election and for any primary under
s. 7.15 (1) (cm). If the municipal clerk or board of election commissioners maintains a Web site on the Internet, the clerk or board of election commissioners shall post a notice of the designation of the alternate site selected under
sub. (1) on the Web site during the same period that notice is displayed in the office of the clerk or board of election commissioners.
6.855(3)
(3) An alternate site under
sub. (1) shall be staffed by the municipal clerk or the executive director of the board of election commissioners, or employees of the clerk or the board of election commissioners.
6.855(4)
(4) An alternate site under
sub. (1) shall be accessible to all individuals with disabilities.
6.855 History
History: 2005 a. 451.
6.86
6.86
Methods for obtaining an absentee ballot. 6.86(1)(a)(a) Any elector of a municipality who is registered to vote whenever required and who qualifies under
ss. 6.20 and
6.85 as an absent elector may make written application to the municipal clerk of that municipality for an official ballot by one of the following methods:
6.86(1)(a)2.
2. In person at the office of the municipal clerk or at an alternate site under
s. 6.855, if applicable.
6.86(1)(a)6.
6. By electronic mail or facsimile transmission as provided in
par. (ac).
6.86(1)(ac)
(ac) Any elector qualifying under
par. (a) may make written application to the municipal clerk for an official ballot by means of facsimile transmission or electronic mail. Any application under this paragraph need not contain a copy of the applicant's original signature. An elector requesting a ballot under this paragraph shall return with the voted ballot a copy of the request bearing an original signature of the elector as provided in
s. 6.87 (4). Except as authorized in
ss. 6.87 (4) (b) 2. to
5. and
6.875 (6), and notwithstanding
s. 343.43 (1) (f), the elector shall transmit a copy of his or her proof of identification in the manner provided in
s. 6.87 (1) unless the elector is a military elector or an overseas elector or the elector has a confidential listing under
s. 6.47 (2).
6.86(1)(ag)
(ag) An elector who is unable to write his or her name due to physical disability may authorize an application to be made by another elector on his or her behalf. In such case, the application shall state that it is made on request and by authorization of a named elector who is unable to sign the application due to physical disability.
6.86(1)(ar)
(ar) Except as authorized in
s. 6.875 (6), the municipal clerk shall not issue an absentee ballot unless the clerk receives a written application therefor from a qualified elector of the municipality. The clerk shall retain each absentee ballot application until destruction is authorized under
s. 7.23 (1). Except as authorized in
s. 6.79 (6) and
(7), if a qualified elector applies for an absentee ballot in person at the clerk's office, the clerk shall not issue the elector an absentee ballot unless the elector presents proof of identification. The clerk shall verify that the name on the proof of identification presented by the elector conforms to the name on the elector's application and shall verify that any photograph appearing on that document reasonably resembles the elector. The clerk shall then enter his or her initials on the certificate envelope indicating that the absentee elector presented proof of identification to the clerk.
6.86(1)(b)
(b) Except as provided in this section, if application is made by mail, the application shall be received no later than 5 p.m. on the 5th day immediately preceding the election. If application is made in person, the application shall be made no earlier than the opening of business on the 3rd Monday preceding the election and no later than 5 p.m. or the close of business, whichever is later, on the Friday preceding the election. Except as provided in
par. (c), if the elector is making written application for an absentee ballot at the partisan primary, the general election, the presidential preference primary, or a special election for national office, and the application indicates that the elector is a military elector, as defined in
s. 6.34 (1), the application shall be received by the municipal clerk no later than 5 p.m. on election day. If the application indicates that the reason for requesting an absentee ballot is that the elector is a sequestered juror, the application shall be received no later than 5 p.m. on election day. If the application is received after 5 p.m. on the Friday immediately preceding the election, the municipal clerk or the clerk's agent shall immediately take the ballot to the court in which the elector is serving as a juror and deposit it with the judge. The judge shall recess court, as soon as convenient, and give the elector the ballot. The judge shall then witness the voting procedure as provided in
s. 6.87 and shall deliver the ballot to the clerk or agent of the clerk who shall deliver it to the polling place or, in municipalities where absentee ballots are canvassed under
s. 7.52, to the municipal clerk as required in
s. 6.88. If application is made under
sub. (2) or
(2m), the application may be received no later than 5 p.m. on the Friday immediately preceding the election.
6.86(1)(c)
(c) If an application is made by mail by a military elector, as defined in
s. 6.22 (1) (b), the application shall be received no later than 5 p.m. on the Friday immediately preceding the election.
6.86(2)(a)(a) An elector who is indefinitely confined because of age, physical illness or infirmity or is disabled for an indefinite period may by signing a statement to that effect require that an absentee ballot be sent to the elector automatically for every election. The application form and instructions shall be prescribed by the board, and furnished upon request to any elector by each municipality. The envelope containing the absentee ballot shall be clearly marked as not forwardable. If any elector is no longer indefinitely confined, the elector shall so notify the municipal clerk.
6.86(2)(b)
(b) The mailing list established under this subsection shall be kept current through all possible means. If an elector fails to cast and return an absentee ballot received under this subsection, the clerk shall notify the elector by 1st class letter or postcard that his or her name will be removed from the mailing list unless the clerk receives a renewal of the application within 30 days of the notification. The clerk shall remove from the list the name of each elector who does not apply for renewal within the 30-day period. The clerk shall remove the name of any other elector from the list upon request of the elector or upon receipt of reliable information that an elector no longer qualifies for the service. The clerk shall notify the elector of such action not taken at the elector's request within 5 days, if possible.
6.86(2m)(a)(a) Except as provided in this subsection, any elector other than an elector who receives an absentee ballot under
sub. (2) or
s. 6.22 (4) or
6.24 (4) (c) may by written application filed with the municipal clerk of the municipality where the elector resides require that an absentee ballot be sent to the elector automatically for every election that is held within the same calendar year in which the application is filed. The application form and instructions shall be prescribed by the board, and furnished upon request to any elector by each municipal clerk. The municipal clerk shall thereupon mail an absentee ballot to the elector for all elections that are held in the municipality during the same calendar year that the application is filed, except that the clerk shall not send an absentee ballot for an election if the elector's name appeared on the registration list in eligible status for a previous election following the date of the application but no longer appears on the list in eligible status. The municipal clerk shall ensure that any envelope containing the absentee ballot is clearly marked as not forwardable. If an elector who files an application under this subsection no longer resides at the same address that is indicated on the application form, the elector shall so notify the municipal clerk. The municipal clerk shall discontinue mailing absentee ballots to an elector under this subsection upon receipt of reliable information that the elector no longer qualifies as an elector of the municipality. In addition, the municipal clerk shall discontinue mailing absentee ballots to an elector under this subsection if the elector fails to return any absentee ballot mailed to the elector. The municipal clerk shall notify the elector of any such action not taken at the elector's request within 5 days, if possible. An elector who fails to cast an absentee ballot but who remains qualified to receive absentee ballots under this subsection may then receive absentee ballots for subsequent elections by notifying the municipal clerk that the elector wishes to continue receiving absentee ballots for subsequent elections.
6.86(2m)(b)
(b) If a municipal clerk is notified by an elector that the elector's residence is changed to another municipality within this state, the clerk shall forward the request to the municipal clerk of that municipality and that municipal clerk shall honor the request, except as provided in this subsection.
6.86(3)(a)1.1. Any elector who is registered and who is hospitalized, may apply for and obtain an official ballot by agent. The agent may apply for and obtain a ballot for the hospitalized absent elector by presenting a form prescribed by the board and containing the required information supplied by the hospitalized elector and signed by that elector, unless the elector is unable to sign due to physical disability. In this case, the elector may authorize another elector to sign on his or her behalf. Any elector signing an application on another elector's behalf shall attest to a statement that the application is made on request and by authorization of the named elector, who is unable to sign the application due to physical disability. The agent shall present this statement along with all other information required under this subdivision. Except as authorized for an elector who has a confidential listing under
s. 6.47 (2) or as authorized under
s. 6.87 (4) (b) 4., the agent shall present any proof of identification required under
sub. (1) (ar). The form shall include a space for the municipal clerk or deputy clerk to enter his or her initials indicating that the agent presented proof of identification to the clerk on behalf of the elector.
6.86(3)(a)2.
2. If a hospitalized elector is not registered, the elector may register by agent under this subdivision at the same time that the elector applies for an official ballot by agent under
subd. 1. To register the elector under this subdivision, the agent shall present a completed registration form that contains the required information supplied by the elector and the elector's signature, unless the elector is unable to sign due to physical disability. In this case, the elector may authorize another elector to sign on his or her behalf. Any elector signing a form on another elector's behalf shall attest to a statement that the application is made on request and by authorization of the named elector, who is unable to sign the form due to physical disability. The agent shall present this statement along with all other information required under this subdivision. The agent shall provide proof of the elector's residence under
s. 6.34.
6.86(3)(b)
(b) When each properly executed form and statement required under
par. (a) is presented to the municipal clerk, if the elector who proposes to vote is qualified, an absentee ballot shall be issued and the name of such hospitalized elector shall be recorded by the clerk or special registration deputy. An agent who is issued an absentee ballot under this section shall present documentation of his or her identity, provide his or her name and address, and attest to a statement that the ballot is received solely for the benefit of a named elector who is hospitalized, and the agent will promptly transmit the ballot to such person.
6.86(3)(c)
(c) An application under
par. (a) 1. may be made and a registration form under
par. (a) 2. may be filed in person at the office of the municipal clerk not earlier than 7 days before an election and not later than 5 p.m. on the day of the election. A list of hospitalized electors applying for ballots under
par. (a) 1. shall be made by the municipal clerk and used to check that the electors vote only once, and by absentee ballot. If the elector is registering for the election after the close of registration or if the elector registered by mail and has not voted in an election in this state, the municipal clerk shall inform the agent that proof of residence under
s. 6.34 is required and the elector shall enclose proof of residence under
s. 6.34 in the envelope with the ballot. The clerk shall verify that the name on any required proof of identification presented by the agent conforms to the name on the elector's application. The clerk shall then enter his or her initials on the carrier envelope indicating that the agent presented proof of identification to the clerk. The agent is not required to enter a signature on the registration list. The ballot shall be sealed by the elector and returned to the municipal clerk either by mail or by personal delivery of the agent; but if the ballot is returned on the day of the election, the agent shall make personal delivery to the polling place serving the hospitalized elector's residence before the closing hour or, in municipalities where absentee ballots are canvassed under
s. 7.52, to the municipal clerk no later than 8 p.m. on election day.
6.86(4)
(4) If a municipality employs an electronic voting system which utilizes a ballot that is inserted into automatic tabulating equipment, the municipality may distribute ballots for utilization with the electronic voting system as absentee ballots or it may distribute paper ballots as absentee ballots.
6.86(5)
(5) Whenever an elector returns a spoiled or damaged absentee ballot to the municipal clerk, or an elector's agent under
sub. (3) returns a spoiled or damaged ballot to the clerk on behalf of an elector, and the clerk believes that the ballot was issued to or on behalf of the elector who is returning it, the clerk shall issue a new ballot to the elector or elector's agent, and shall destroy the spoiled or damaged ballot. Any request for a replacement ballot under this subsection must be made within the applicable time limits under
subs. (1) and
(3) (c).
6.86(6)
(6) Except as authorized in
sub. (5) and
s. 6.87 (9), if an elector mails or personally delivers an absentee ballot to the municipal clerk, the municipal clerk shall not return the ballot to the elector. An elector who mails or personally delivers an absentee ballot to the municipal clerk at an election is not permitted to vote in person at the same election on election day.
6.86 History
History: 1975 c. 85 ss.
37,
38,
65;
1975 c. 90,
199,
200,
275,
422;
1977 c. 394 ss.
14,
40,
41;
1979 c. 232,
311;
1981 c. 391;
1983 a. 183,
484;
1985 a. 304 ss.
69,
156;
1987 a. 391;
1995 a. 313;
1999 a. 182;
2001 a. 51;
2003 a. 265;
2005 a. 451;
2011 a. 23,
75,
115,
227.
6.86 Annotation
The sub. (1) (ar) requirement that an elector must apply for an absentee ballot is mandatory. The ballots of absentee voters who do not file a written application must not be included in certified election results. Lee v. Paulson,
2001 WI App 19,
241 Wis. 2d 38,
623 N.W.2d 577,
00-1626.
6.865
6.865
Federal absentee ballots. 6.865(1)
(1) In this section, "military elector" and "overseas elector" have the meanings given under
s. 6.34 (1).
6.865(2)
(2) A federal postcard registration and absentee ballot request form may be used to apply for an absentee ballot under
s. 6.86 (1) if the form is completed in such manner that the municipal clerk or board of election commissioners with whom it is filed is able to determine that the applicant is an elector of this state and of the ward or election district where the elector seeks to vote.
6.865(3m)
(3m) A military elector may indicate an alternate address on his or her absentee ballot application. If the elector's ballot is returned as undeliverable prior to the deadline for receipt and return of absentee ballots under
s. 6.87 (6) and the elector remains eligible to receive absentee ballots under this subsection, the municipal clerk shall immediately send or transmit an absentee ballot to the elector at the alternate address.
6.865(4)
(4) If the municipal clerk or board of election commissioners rejects a request for an absentee ballot from a military elector or an overseas elector, the clerk or board of election commissioners shall promptly inform the elector of the reason for the rejection.
6.869
6.869
Uniform instructions. The board shall prescribe uniform instructions for municipalities to provide to absentee electors. The instructions shall include the specific means of electronic communication that an absentee elector may use to file an application for an absentee ballot and, if the absentee elector is required to register, to request a registration form or change his or her registration. The instructions shall include information concerning whether proof of identification is required to be presented or enclosed. The instructions shall also include information concerning the procedure for correcting errors in marking a ballot and obtaining a replacement for a spoiled ballot. The procedure shall, to the extent possible, respect the privacy of each elector and preserve the confidentiality of each elector's vote.
6.869 History
History: 2003 a. 265;
2011 a. 23,
75,
227.
6.87
6.87
Absent voting procedure. 6.87(1)
(1) Upon proper request made within the period prescribed in
s. 6.86, the municipal clerk or a deputy clerk authorized by the municipal clerk shall write on the official ballot, in the space for official endorsement, the clerk's initials and official title. Unless application is made in person under
s. 6.86 (1) (ar), the absent elector is exempted from providing proof of identification under
sub. (4) (b) 2. or
3., or the applicant is a military or overseas elector, the absent elector shall enclose a copy of his or her proof of identification or any authorized substitute document with his or her application. The municipal clerk shall verify that the name on the proof of identification conforms to the name on the application. The clerk shall not issue an absentee ballot to an elector who is required to enclose a copy of proof of identification or an authorized substitute document with his or her application unless the copy is enclosed and the proof is verified by the clerk.
6.87(2)
(2) Except as authorized under
sub. (3) (d), the municipal clerk shall place the ballot in an unsealed envelope furnished by the clerk. The envelope shall have the name, official title and post-office address of the clerk upon its face. The other side of the envelope shall have a printed certificate which shall include a space for the municipal clerk or deputy clerk to enter his or her initials indicating that if the absentee elector voted in person under
s. 6.86 (1) (ar), the elector presented proof of identification to the clerk and the clerk verified the proof presented. The certificate shall also include a space for the municipal clerk or deputy clerk to enter his or her initials indicating that the elector is exempt from providing proof of identification because the individual is a military or overseas elector or is exempted from providing proof of identification under
sub. (4) (b) 2. or
3. The certificate shall be in substantially the following form:
[STATE OF ....
County of ....]
