Elec. Code, § 14107

(a) The roster to be kept by each precinct board shall contain all of the following:

(1) Space for the voter’s signature.

(2) The residence address of the voter.

(3) At the heading of each page or signature area, the following words: “WARNING: It is a crime punishable by imprisonment in the state prison or in county jail for anyone to fraudulently vote, fraudulently attempt to vote, vote more than once, attempt to vote more than one, impersonate a voter, or attempt to impersonate a voter (Sec. 18560, Elections Code).”

(4) Immediately below the final signature on the roster, the following statements:

(A) We hereby certify that all voters whose signatures appear hereinbefore in this roster voted this day excepting the following who, after signing the roster, failed to vote or were challenged and denied the right to vote.

No.______Name No.______Name

______ ______ ______ ______ ______ ______

(B) We further certify that the number of voters who voted in this precinct at this election is ____, and that the above list of voters, less those who did not vote as enumerated, constitutes the roster of this precinct for this election.

We further certify that the total number of official ballots received, voted, rejected, spoiled and canceled, found in the ballot container and the number accounted for is as indicated on the ballot statement.

We further certify that the assisted voters list and challenge list show a complete list of all voters assisted or challenged.

______Clerk ______Clerk ______Clerk ______Inspector

All members of the precinct board shall sign this certificate.

(b) When votes are counted at the precinct, all members of the board shall also sign the certificate of performance prescribed in Section 15280.