This form should be used to report instances of voting-related behavior that you believe is not compliant with election laws. Please record your experience as you remember it.

Note the certification at the end of the survey that this information is true and correct to the best of your knowledge and belief. If you have any questions regarding incident reporting please reach out to the DeKalb County Republican Party at 404-334-0182.

For any questions you have about the election process that you are observing, call the Elections Superintendent at 404-298-4020.

If you are attempting to report poll pad, scanner or BMD numbers, please follow this link: https://www.surveymonkey.com/r/pollnumberreport

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* 1. At what Time and Date did this incident occur?

Date
Time

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* 3. Provide a brief summary of the incident:

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* 4. Which of the following did this incident involve (You may select more than one answer):

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* 5. Provide a detailed description of the incident:

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* 6. Please Share your Contact Information so we may reach you if we have a question:

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* 7. Do you affirm/certify under penalty of perjury under the laws of the state of Georgia that the information you have provided on this form is true and correct to the best of your knowledge and belief?

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* 8. What is your Name?

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* 9. What is today's Date?

Date

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