Form EAC003C "Voting System Anomaly Reporting Form for Voluntary Reporting of Voting System Anomalies"

What Is Form EAC003C?

This is a legal form that was released by the U.S. Election Assistance Commission and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • The latest available edition released by the U.S. Election Assistance Commission;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form EAC003C by clicking the link below or browse more documents and templates provided by the U.S. Election Assistance Commission.

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Download Form EAC003C "Voting System Anomaly Reporting Form for Voluntary Reporting of Voting System Anomalies"

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U.S. Election Assistance Commission
Print Form
Submit by Email
OMB Control # 3265-0004
Voting System Anomaly Reporting Form
For VOLUNTARY reporting of Voting System Anomalies
A. Election Official:
C. Description of Anomaly or Event:
1.
Name, Title, Jurisdiction
11.
Date of Occurrence
Polling Place Name or Location
12.
Election Type
Primary
General
Special
13.
Was this your first election using this system?
2.
Phone Number
YES
NO
3.
Email
14.
Description of Anomaly
Reported to Manufacturer?
4.
YES
NO
B. Product Description:
5.
Manufacturer Name
6.
Type of Voting System
DRE
Ballot Marking Device
Optical Scan
Other
7.
System Model
8.
Hardware & Software Versions
9.
Unit Serial Number
10.
EAC Certification Number
Form EAC 003C
Page 1 of 2
U.S. Election Assistance Commission
Print Form
Submit by Email
OMB Control # 3265-0004
Voting System Anomaly Reporting Form
For VOLUNTARY reporting of Voting System Anomalies
A. Election Official:
C. Description of Anomaly or Event:
1.
Name, Title, Jurisdiction
11.
Date of Occurrence
Polling Place Name or Location
12.
Election Type
Primary
General
Special
13.
Was this your first election using this system?
2.
Phone Number
YES
NO
3.
Email
14.
Description of Anomaly
Reported to Manufacturer?
4.
YES
NO
B. Product Description:
5.
Manufacturer Name
6.
Type of Voting System
DRE
Ballot Marking Device
Optical Scan
Other
7.
System Model
8.
Hardware & Software Versions
9.
Unit Serial Number
10.
EAC Certification Number
Form EAC 003C
Page 1 of 2
Instructions
This form provides for the reporting of voting system anomalies by election officials. This form is part of the EAC Quality
Monitoring Program. The use of this form is voluntary. Information regarding its use can be found in Section 8.7 of the
Manual.
This form is self-explanatory.
This information is required for the EAC to provide for the certification of voting systems as required by 42 U.S.C. Section
15371. This information will be used solely to administer the EAC Testing and Certification Program. This program is
voluntary, however, individuals who wish to participate must meet the requirements of the Program. This information will
be made public consistent with the requirements of the Freedom of Information Act, the Trade Secrets Act, and any other
applicable Federal law or regulation. Public reporting burden for this collection of information is estimated to average
about 82 hours for completion of this form. This estimate includes the time for reviewing the instructions, gathering
information and completing the form. Send comments regarding this burden estimate to the Testing and Certification
Program Director, Election Assistance Commission, 1225 New York Avenue, N.W., Suite 1100, Washington, DC 20005.
Notwithstanding any other provision of law, no person is required to respond to, nor shall any person be subject to a
penalty for failure to respond to, or comply with, a collection of information subject to the requirements of the Paperwork
Reduction Act, unless that collection of information displays a currently valid OMB Control Number.
Form EAC 003C
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