(Equipment Name and Serial Number)

(Date of Election)

(Equipment Name and Serial Number)

(Signature of Operator

(Jurisdiction)

(Signature of Election Authority)

( I )

Pretabulation Test

Begun

Ended

RUN MORE

NUMBER

THAN ONCE

PRECINCT

TIME RUN

OF BALLOTS

(YES/NO)

IF YES, EXPLAIN

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

Post-tabulation text:

Begun

Ended

(II)

WAS PROGRAM ACCESSED (CHANGED) BETWEEN PUBLIC TEST AND POST TEST?  IF YES, WAS THE PROGRAM ACCESSED IN RESPONSE TO A CONSOLE MESSAGE, WHAT WAS THE CONSOLE MESSAGE AND WHAT WAS THE CHANGE, EXPLAN:

Pretabulation Test Rerun Time:

Begun

Ended

(III)

USE THIS SECTION TO REPORT REQUIREMENT REPAIRS OR REPLACEMENTS

TIME OF

TIME BACK

MACHINE

SERIAL NUMBER

MALFUNCTION

IN SERVICE

REPLACED

DESCRIPTION OF MALFUNCTION:

PRETABULATION TEST RERUN

TIME:

BEGUN

ENDED