Statement of the Votes Cast For

RFP-4-43

Attachment J

Indiana Election Division

Statewide Voter Registration System

CEB Reports

J- 1

COUNTY ELECTION REPORT (CEB-9)

State Form 47923 (R5/12-03)

Indiana Election Commission (IC 3-6-5-17; IC 3-6-5-17.5)

INSTRUCTIONS: Each county election board shall submit a report to the Indiana Election Division after each primary, general, and special election. The report must be mailed or hand delivered to the Indiana Election Division, Indiana Government Center South, 302 West Washington Street, Room E-204, Indianapolis, IN 46204-2743 not later than 14 days after each election.

COUNTY ELECTION REPORT

FOR THE ELECTION CONDUCTED ON , 20_

REGISTRATION AND TURNOUT:

1. Number of registered voters in county at close of registration for this election: ______

2. If the election was held only in part of the county, the number of registered voters in that part of the county at close of

registration for this election ______

3. Number of voters voting in person at the polls: ______

4. Number of all voters voting absentee: ______

5. Total number of voters who voted in this election (should equal #3 + #4): ______

#6 - #8 are for General Elections Only – Otherwise, put NA

6. The combined total number of absentee ballots sent by county to military and overseas voters ______

7. Total number of ballots in #6 returned by voters ______

8. Total number of ballots in #7 counted ______

ELECTION BUDGET AND EQUIPMENT:

9. BUDGETED cost for this election. Estimate if necessary: ______

10. What types of voting systems did the county use in this election?

(check one) paper ballot lever machine direct recording electronic voting unit punch card optical scan

11. Name of the vendor of the voting system the county used in this election: ______

ENCLOSURES. Please attach sheets or printouts with the following:

12. Describe any malfunction or other problem with your voting system during the election.

(Attach an extra page if necessary): ______

13. Canvasser sheets (official election results by precinct).

(check box) County has provided an electronic version of the canvasser sheets to the Indiana Election Division.

14. Number of registered voters for each precinct in the county.

15. Names and mailing addresses for your county election board members and any board of voter registration officers.

16. Any sheets provided by the Election Division containing requests for additional information (including training and education survey).

County / Signature / Title

CERTIFIED STATEMENT OF THE CIRCUIT COURT CLERK (CEB-10)

OF THE VOTES CAST FOR GOVERNOR AND LIEUTENANT GOVERNOR

AT THE GENERAL ELECTION

State Form 47924 (R2/12-03)

Indiana Election Commission (IC 3-12-5-5)

INSTRUCTIONS: If additional write-in candidates receive votes in a county, attach a copy of this form listing the votes for those candidates. Not later than noon, November 8, 2004, each circuit court clerk shall prepare this statement. The clerk transmits one copy to the Indiana Election Division by hand delivery or certified mail. The Election Division transmits this copy to the Speaker of the Indiana House of Representatives no later than the date of the joint convention of the Indiana House and Senate canvass the votes cast for governor and lieutenant governor (no later than Monday, January 10, 2005.)

STATE OF INDIANA

COUNTY OF ______

TO THE INDIANA ELECTION DIVISION:

As required by Indiana Code 3-12-5-5, and as the duly elected and acting circuit court clerk of this county, I certify that at the general election held on November 2, 2004, the county election board of this county canvassed the votes cast in the precincts of this county and determined that the following candidates received the number of votes indicated below for the offices of governor and lieutenant governor:

DEMOCRATIC PARTY

Governor______
received ______votes.
Lieutenant Governor ______

LIBERTARIAN PARTY

Governor______
received ______votes.
Lieutenant Governor ______

REPUBLICAN PARTY

Governor______
received ______votes.
Lieutenant Governor ______

WRITE IN

Governor______
received ______votes.
Lieutenant Governor ______

WRITE IN

Governor______
received ______votes.
Lieutenant Governor ______

CERTIFIED, THIS THE ______DAY OF NOVEMBER, 2004:

______

CIRCUIT COURT CLERK

STATEMENT OF THE CIRCUIT COURT CLERK (CEB-11)

OF THE VOTES CAST FOR LOCAL OFFICES

AT THE GENERAL ELECTION

State Form 47924 (R5/12-03)

Indiana Election Commission (IC 3-12-5-1)

INSTRUCTIONS: Not later than NOON, Monday, November 8, 2004, each circuit court clerk shall prepare this statement and transmit a copy to the Indiana Election Division by hand delivery or certified mail. If an office is not on the ballot in the county, write “NA” on the first line under the office title. If sufficient spaces are not provided under a particular office, photocopy the relevant page(s) or attach the information on separate sheets.
USE THE FOLLOWING ABBREVIATIONS: (D) refers to Democratic Party; (L) refers to Libertarian Party; (R) refers to Republican Party. Please print the full name of any other party following the candidate’s name. (I) refers to an independent candidate; (W) refers to a write-in candidate.
EXAMPLE: Mary Smith (I) received 1,234 votes. John Doe (W) received 56 votes.
The candidate declared elected is marked with an “*”.
Certify Judges results on CEB-13 form.

STATE OF INDIANA

COUNTY OF ______

TO THE INDIANA ELECTION DIVISION:

As required by Indiana Code 3-12-5-1(a) and (b)(3), and as the duly elected and acting circuit court clerk of this county, I certify that at the general election held on November 2, 2004, the county election board of this county canvassed the votes cast in the precincts of this county and determined that the following candidates received the number of votes indicated.

I further certify that the county election board acted under IC 3-12-4-9 to declare candidates to be elected to the indicted offices, and that the names of the elected individuals are accurately set forth for the Governor to commission these officers under IC 4-3-1-5.

CLERK OF THE CIRCUIT COURT

______( )received ______votes*.

______( )received ______votes.

COUNTY AUDITOR

______( )received ______votes*.

______( )received ______votes.

COUNTY RECORDER

______( )received ______votes*.

______( )received ______votes.

COUNTY TREASURER

______( )received ______votes*.

______( )received ______votes.

COUNTY SHERIFF

______( )received ______votes*.

______( )received ______votes.

COUNTY CORONER

______( )received ______votes*.

______( )received ______votes.

COUNTY SURVEYOR

______( )received ______votes*.

______( )received ______votes.

COUNTY ASSESSOR

______( )received ______votes*.

______( )received ______votes.

COUNTY COMMISSIONER ______DISTRICT

______( )received ______votes*.

______( )received ______votes.

COUNTY COMMISSIONER ______DISTRICT

______( )received ______votes*.

______( )received ______votes.

COUNTY COUNCIL ______DISTRICT

______( )received ______votes*.

______( )received ______votes.

COUNTY COUNCIL ______DISTRICT

______( )received ______votes*.

______( )received ______votes.

COUNTY COUNCIL ______DISTRICT

______( )received ______votes*.

______( )received ______votes.

COUNTY COUNCIL ______DISTRICT

______( )received ______votes*.

______( )received ______votes.

COUNTY COUNCIL ______DISTRICT

______( )received ______votes*.

______( )received ______votes.

COUNTY COUNCIL ______DISTRICT

______( )received ______votes*.

______( )received ______votes.

COUNTY COUNCIL ______DISTRICT

______( )received ______votes*.

______( )received ______votes.

TOWN COUNCIL, TOWN OF ______

______( )received ______votes*.

______( )received ______votes.

TOWN COUNCIL, TOWN OF ______

______( )received ______votes*.

______( )received ______votes.

TOWN COUNCIL, TOWN OF ______

______( )received ______votes*.

______( )received ______votes.

TOWN JUDGE, TOWN OF ______

______( )received ______votes*.

______( )received ______votes.

TOWN CLERK-TREASURER, TOWN OF ______

______( )received ______votes*.

______( )received ______votes.

CERTIFIED, THIS THE ______DAY OF NOVEMBER, 2004:

______

SIGNATURE OF CIRCUIT COURT CLERK

______

PRINTED NAME

STATEMENT OF THE CIRCUIT COURT CLERK OF THE VOTES CAST (CEB-12)

FOR OR AGAINST THE RETENTION

OF A JUSTICE OF THE SUPREME COURT OR

A JUDGE OF AN APPELATE COURT

State Form 47926 (R6/9-02)

Indiana Election Commission (IC 3-12-5-1)

INSTRUCTIONS: Not later than NOON, Tuesday, November 12, 2002, each circuit court clerk shall prepare this statement and transmit a copy to the Indiana Election Division by hand delivery or certified mail. If a judge listed below was not on the ballot in your county, write “NA.”
EXAMPLE: “YES” received 789 votes.

STATE OF INDIANA)

)SS:

COUNTY OF ______)

TO THE INDIANA ELECTION DIVISION:

As required by Indiana Code 3-12-5-1, and as the duly elected and acting circuit court clerk of this county, I certify that at the general election held on November 5, 2002, the county election board of this county canvassed the votes cast in the precincts of this county and determined that the number of votes cast for or against the retention of the following Justice of the Indiana Supreme Court or Judges of the Indiana Court of Appeals were as indicated below:

JUDICIAL RETENTION PUBLIC QUESTIONS

INDIANA SUPREME COURT

1. Shall Justice Robert D. Rucker be retained in office?

“YES” received ______votes.

“NO” received ______votes.

INDIANA COURT OF APPEALS, FIRST DISTRICT

2. Shall Judge John G. Baker be retained in office?

“YES” received ______votes.

“NO” received ______votes.

INDIANA COURT OF APPEALS, SECOND DISTRICT

3. Shall Judge Patrick D. Sullivan be retained in office?

“YES” received ______votes.

“NO” received ______votes.

INDIANA COURT OF APPEALS, THIRD DISTRICT

4. Shall Judge Michael P. Barnes be retained in office?

“YES” received ______votes.

“NO” received ______votes.

INDIANA COURT OF APPEALS, THIRD DISTRICT

5. Shall Judge Paul D. Mathias be retained in office?

“YES” received ______votes.

“NO” received ______votes.

INDIANA COURT OF APPEALS, FIFTH DISTRICT

6. Shall Judge Nancy H. Vaidik be retained in office?

“YES” received ______votes.

“NO” received ______votes.

CERTIFIED, THIS THE ______DAY OF NOVEMBER, 2002:

______CLERK’S

SIGNATURE OF CIRCUIT COURT CLERK SEAL

______

PRINTED NAME

STATEMENT OF THE CIRCUIT COURT CLERK (CEB-13)

OF THE VOTES CAST FOR FEDERAL, STATE, LEGISLATIVE, AND

JUDICIAL OFFICES AT THE GENERAL ELECTION

State Form 47925 (R3/12-03)

Indiana Election Commission (IC 3-12-5-6; 3-12-5-7)

INSTRUCTIONS: Not later than NOON, Monday, November 8, 2004, each circuit court clerk shall prepare this statement and transmit a copy to the Indiana Election Division by hand delivery or certified mail. If an office is not on the ballot in the county, write “NA” on the first line under the office title. If sufficient spaces are not provided under a particular office, photocopy the relevant page(s) or attach the information on separate sheets. The votes cast for candidates for governor and lieutenant governor are certified on the CEB-10 form.
USE THE FOLLOWING ABBREVIATIONS: (D) refers to Democratic Party; (G) refers to Green Party; (L) refers to Libertarian Party; (R) refers to Republican Party. Please print the full name of any other party following the candidate’s name. (I) refers to an independent candidate; (W) refers to a write-in candidate.
EXAMPLE: Mary Smith (I) received 1,234 votes. John Doe (W) received 56 votes.

STATE OF INDIANA

COUNTY OF ______

TO THE INDIANA ELECTION DIVISION:

As required by Indiana Code 3-12-5-6, and as the duly elected and acting circuit court clerk of this county, I certify that at the general election held on November 2, 2004, the county election board of this county canvassed the votes cast in the precincts of this county and determined that the following candidates received the number of votes indicated.

ELECTORS FOR PRESIDENT AND VICE PRESIDENT OF THE UNITED STATES

______( D )received ______votes.

______

______( L )received ______votes.

______

______( R )received ______votes.

______

______( )received ______votes.

______

______( )received ______votes.

______

______( )received ______votes.

______

______( )received ______votes.

______

UNITED STATES SENATOR

______( D )received ______votes.

______( L )received ______votes.

______( R )received ______votes.

______( )received ______votes.

ATTORNEY GENERAL

______( D )received ______votes.

______( L )received ______votes.

______( R )received ______votes.

______( )received ______votes.

SUPERINTENDENT OF PUBLIC INSTRUCTION

______( D )received ______votes.

______( L )received ______votes.

______( R )received ______votes.

______( )received ______votes.

UNITED STATES REPRESENTATIVE, ______DISTRICT

______( D )received ______votes.

______( L )received ______votes.

______( R )received ______votes.

______( )received ______votes.

UNITED STATES REPRESENTATIVE, ______DISTRICT

______( D )received ______votes.

______( L )received ______votes.

______( R )received ______votes.

______( )received ______votes.

UNITED STATES REPRESENTATIVE, ______DISTRICT

______( D )received ______votes.

______( L )received ______votes.

______( R )received ______votes.

______( )received ______votes.

STATE SENATOR, ______DISTRICT

______( D )received ______votes.

______( L )received ______votes.

______( R )received ______votes.

______( )received ______votes.

STATE SENATOR, ______DISTRICT

______( D )received ______votes.

______( L )received ______votes.

______( R )received ______votes.

______( )received ______votes.

STATE SENATOR, ______DISTRICT

______( D )received ______votes.

______( L )received ______votes.

______( R )received ______votes.

______( )received ______votes.

STATE SENATOR, ______DISTRICT

______( D )received ______votes.

______( L )received ______votes.

______( R )received ______votes.

______( )received ______votes.

STATE SENATOR, ______DISTRICT

______( D )received ______votes.

______( L )received ______votes.

______( R )received ______votes.

______( )received ______votes.

STATE SENATOR, ______DISTRICT

______( D )received ______votes.

______( L )received ______votes.

______( R )received ______votes.

______( )received ______votes.

STATE SENATOR, ______DISTRICT

______( D )received ______votes.

______( L )received ______votes.

______( R )received ______votes.

______( )received ______votes.

STATE SENATOR, ______DISTRICT

______( D )received ______votes.

______( L )received ______votes.

______( R )received ______votes.

______( )received ______votes.

STATE SENATOR, ______DISTRICT

______( D )received ______votes.

______( L )received ______votes.

______( R )received ______votes.

______( )received ______votes.

STATE SENATOR, ______DISTRICT

______( D )received ______votes.

______( L )received ______votes.

______( R )received ______votes.

______( )received ______votes.

STATE REPRESENTATIVE, ______DISTRICT

______( D )received ______votes.

______( L )received ______votes.

______( R )received ______votes.

______( )received ______votes.

STATE REPRESENTATIVE, ______DISTRICT

______( D )received ______votes.

______( L )received ______votes.

______( R )received ______votes.

______( )received ______votes.

STATE REPRESENTATIVE, ______DISTRICT

______( D )received ______votes.

______( L )received ______votes.

______( R )received ______votes.

______( )received ______votes.

STATE REPRESENTATIVE, ______DISTRICT

______( D )received ______votes.

______( L )received ______votes.

______( R )received ______votes.

______( )received ______votes.

STATE REPRESENTATIVE, ______DISTRICT

______( D )received ______votes.

______( L )received ______votes.

______( R )received ______votes.

______( )received ______votes.

STATE REPRESENTATIVE, ______DISTRICT

______( D )received ______votes.

______( L )received ______votes.

______( R )received ______votes.

______( )received ______votes.

STATE REPRESENTATIVE, ______DISTRICT

______( D )received ______votes.

______( L )received ______votes.

______( R )received ______votes.

______( )received ______votes.

STATE REPRESENTATIVE, ______DISTRICT

______( D )received ______votes.

______( L )received ______votes.

______( R )received ______votes.

______( )received ______votes.

STATE REPRESENTATIVE, ______DISTRICT

______( D )received ______votes.

______( L )received ______votes.

______( R )received ______votes.

______( )received ______votes.

STATE REPRESENTATIVE, ______DISTRICT

______( D )received ______votes.

______( L )received ______votes.

______( R )received ______votes.

______( )received ______votes.

STATE REPRESENTATIVE, ______DISTRICT

______( D )received ______votes.

______( L )received ______votes.

______( R )received ______votes.

______( )received ______votes.

STATE REPRESENTATIVE, ______DISTRICT

______( D )received ______votes.

______( L )received ______votes.

______( R )received ______votes.

______( )received ______votes.

JUDGE, SUPERIOR COURT # ______

______( D )received ______votes.

______( L )received ______votes.

______( R )received ______votes.

______( )received ______votes.

JUDGE, SUPERIOR COURT # ______

______( D )received ______votes.

______( L )received ______votes.

______( R )received ______votes.

______( )received ______votes.

JUDGE, SUPERIOR COURT # ______

______( D )received ______votes.

______( L )received ______votes.

______( R )received ______votes.

______( )received ______votes.

JUDGE, SUPERIOR COURT # ______

______( D )received ______votes.

______( L )received ______votes.

______( R )received ______votes.

______( )received ______votes.

JUDGE OF THE CIRCUIT COURT ______DIVISION

______( D )received ______votes.

______( L )received ______votes.

______( R )received ______votes.

______( )received ______votes.

JUDGE OF THE CIRCUIT COURT ______DIVISION

______( D )received ______votes.

______( L )received ______votes.

______( R )received ______votes.

______( )received ______votes.

JUDGE OF THE COUNTY COURT ______DIVISION

______( D )received ______votes.

______( L )received ______votes.

______( R )received ______votes.

______( )received ______votes.

JUDGE OF ______COURT ______DIVISION

______( D )received ______votes.

______( L )received ______votes.

______( R )received ______votes.

______( )received ______votes.

CERTIFIED, THIS THE ______DAY OF NOVEMBER, 2004:

______

SIGNATURE OF CIRCUIT COURT CLERK

______

PRINTED NAME

STATEMENT OF THE VOTES CAST FOR (CEB-23)

NOMINATION TO OFFICES AND FOR ELECTION AS

STATE CONVENTION DELEGATE

IN THE DEMOCRATIC PARTY PRIMARY

State Form 48645 (R4/12-03)

Indiana Election Commission (IC 3-8-4-5, 3-8-7-5, 3-10-1-33, 3-12-4-9, 3-12-5-1)

INSTRUCTIONS: Not later than NOON, Monday, May 10, 2004, each circuit court clerk shall prepare this statement and transmit a copy to the Indiana Election Division by hand delivery or certified mail. If an office is not on the ballot in the county, write “NA” on the first line under the office title. If sufficient spaces are not provided under a particular office, photocopy the relevant page(s) or attach the information on separate sheets.
EXAMPLE: Mary Smith received 1,234 votes. John Doe received 56 votes.

STATE OF INDIANA

COUNTY OF ______

TO THE INDIANA ELECTION DIVISION:

As required by Indiana Code 3-10-1-33, and as the duly elected and acting circuit court clerk of this county and secretary of the county election board, I certify that at the primary election held on May 7, 2002, the county election board of this county canvassed the votes cast in the precincts of this county and determined that the following candidates received the number of votes indicated.

PRESIDENT OF THE UNITED STATES

______,received ______votes.

UNITED STATES SENATOR

______,received ______votes.

GOVERNOR

______,received ______votes.

UNITED STATES REPRESENTATIVE, ______DISTRICT

______,received ______votes.

UNITED STATES REPRESENTATIVE, ______DISTRICT

______,received ______votes.

UNITED STATES REPRESENTATIVE, ______DISTRICT

______,received ______votes.

STATE SENATOR, ______DISTRICT

______,received ______votes.

STATE SENATOR, ______DISTRICT

______,received ______votes.

STATE SENATOR, ______DISTRICT

______,received ______votes.

STATE SENATOR, ______DISTRICT

______,received ______votes.

STATE SENATOR, ______DISTRICT

______,received ______votes.

STATE SENATOR, ______DISTRICT

______,received ______votes.

STATE SENATOR, ______DISTRICT

______,received ______votes.

STATE REPRESENTATIVE, ______DISTRICT

______,received ______votes.

STATE REPRESENTATIVE, ______DISTRICT

______,received ______votes.

STATE REPRESENTATIVE, ______DISTRICT

______,received ______votes.

STATE REPRESENTATIVE, ______DISTRICT

______,received ______votes.

STATE REPRESENTATIVE, ______DISTRICT

______,received ______votes.

STATE REPRESENTATIVE, ______DISTRICT

______,received ______votes.

STATE REPRESENTATIVE, ______DISTRICT

______,received ______votes.

STATE REPRESENTATIVE, ______DISTRICT

______,received ______votes.

STATE REPRESENTATIVE, ______DISTRICT

______,received ______votes.

STATE REPRESENTATIVE, ______DISTRICT

______,received ______votes.

STATE REPRESENTATIVE, ______DISTRICT

______,received ______votes.

STATE REPRESENTATIVE, ______DISTRICT

______,received ______votes.

STATE REPRESENTATIVE, ______DISTRICT

______,received ______votes.

STATE REPRESENTATIVE, ______DISTRICT

______,received ______votes.

STATE REPRESENTATIVE, ______DISTRICT

______,received ______votes.

STATE REPRESENTATIVE, ______DISTRICT

______,received ______votes.

JUDGE, SUPERIOR COURT # ______

______,received ______votes.

JUDGE, SUPERIOR COURT # ______

______,received ______votes.

JUDGE, SUPERIOR COURT # ______

______,received ______votes.

JUDGE, SUPERIOR COURT # ______

______,received ______votes.

JUDGE OF THE CIRCUIT COURT ______DIVISION

______,received ______votes.

JUDGE OF THE CIRCUIT COURT ______DIVISION

______,received ______votes.

JUDGE OF THE CIRCUIT COURT ______DIVISION

______,received ______votes.

JUDGE OF THE CIRCUIT COURT ______DIVISION

______,received ______votes.

JUDGE OF THE CIRCUIT COURT ______DIVISION

______,received ______votes.

JUDGE OF THE COUNTY COURT ______DIVISION

______,received ______votes.

JUDGE OF THE ______COURT, ______DIVISION

______,received ______votes.

INSTRUCTIONS: If no candidate was nominated, write “NONE” on the first line, and SKIP to the next entry.
For township offices, list townships in alphabetical order.

As required by Indiana Code 3-8-7-5, and as the duly elected circuit court clerk of this county and the secretary of the county election board, I certify that:

(1) the following individuals were nominated for the offices listed below; and

(2) the individuals reside at the addresses and in the congressional districts listed below, according to the declarations of candidacy filed with the county election board.

CLERK OF THE CIRCUIT COURT

CONGRESSIONAL DISTRICT ______

Printed Name of Nominated Candidate / Residence Address / City/Town, Zip Code

COUNTY AUDITOR

CONGRESSIONAL DISTRICT ______

Printed Name of Nominated Candidate / Residence Address / City/Town, Zip Code

COUNTY RECORDER

CONGRESSIONAL DISTRICT ______

Printed Name of Nominated Candidate / Residence Address / City/Town, Zip Code

COUNTY TREASURER

CONGRESSIONAL DISTRICT ______

Printed Name of Nominated Candidate / Residence Address / City/Town, Zip Code

COUNTY SHERIFF

CONGRESSIONAL DISTRICT ______

Printed Name of Nominated Candidate / Residence Address / City/Town, Zip Code

COUNTY CORONER

CONGRESSIONAL DISTRICT ______

Printed Name of Nominated Candidate / Residence Address / City/Town, Zip Code

COUNTY SURVEYOR

CONGRESSIONAL DISTRICT ______

Printed Name of Nominated Candidate / Residence Address / City/Town, Zip Code

COUNTY ASSESSOR

CONGRESSIONAL DISTRICT ______

Printed Name of Nominated Candidate / Residence Address / City/Town, Zip Code

COUNTY COMMISSIONER, ______DISTRICT

CONGRESSIONAL DISTRICT ______

Printed Name of Nominated Candidate / Residence Address / City/Town, Zip Code

COUNTY COMMISSIONER, ______DISTRICT

CONGRESSIONAL DISTRICT ______

Printed Name of Nominated Candidate / Residence Address / City/Town, Zip Code

COUNTY COUNCIL MEMBER, ______DISTRICT

CONGRESSIONAL DISTRICT ______

Printed Name of Nominated Candidate / Residence Address / City/Town, Zip Code

COUNTY COUNCIL MEMBER, ______DISTRICT

CONGRESSIONAL DISTRICT ______

Printed Name of Nominated Candidate / Residence Address / City/Town, Zip Code

COUNTY COUNCIL MEMBER, ______DISTRICT

CONGRESSIONAL DISTRICT ______

Printed Name of Nominated Candidate / Residence Address / City/Town, Zip Code

COUNTY COUNCIL MEMBER, ______DISTRICT

CONGRESSIONAL DISTRICT ______

Printed Name of Nominated Candidate / Residence Address / City/Town, Zip Code

STATE CONVENTION DELEGATES

As required by Indiana Code 3-8-4-5 and 3-8-7-5, I certify that the attached document (marked as “ATTACHMENT A”) lists the following concerning each candidate elected as a state convention delegate, all as set forth on the declarations of candidacy filed with the county election board:

(1) The name of each candidate elected as delegate.

(2) The mailing address of the candidate.

(3) The U.S. Congressional district in which the candidate resides.

(4) The state convention delegate district name or number (if any) that the delegate was elected to represent.

Statement of the Votes Cast For

COUNTY ELECTION REPORT

FOR THE ______ELECTION CONDUCTED ON ______, 20_____

OF THE VOTES CAST FOR GOVERNOR AND LIEUTENANT GOVERNOR

AT THE GENERAL ELECTION

DEMOCRATIC PARTY

LIBERTARIAN PARTY

REPUBLICAN PARTY

WRITE IN

WRITE IN

OF THE VOTES CAST FOR LOCAL OFFICES

AT THE GENERAL ELECTION

FOR OR AGAINST THE RETENTION

OF A JUSTICE OF THE SUPREME COURT OR

A JUDGE OF AN APPELATE COURT

INDIANA SUPREME COURT

INDIANA COURT OF APPEALS, FIRST DISTRICT

INDIANA COURT OF APPEALS, SECOND DISTRICT

INDIANA COURT OF APPEALS, THIRD DISTRICT

INDIANA COURT OF APPEALS, THIRD DISTRICT

INDIANA COURT OF APPEALS, FIFTH DISTRICT

OF THE VOTES CAST FOR FEDERAL, STATE, LEGISLATIVE, AND

JUDICIAL OFFICES AT THE GENERAL ELECTION

NOMINATION TO OFFICES AND FOR ELECTION AS

STATE CONVENTION DELEGATE

FOR THE ELECTION CONDUCTED ON , 20_