walsh incident report (PDF)

Use separate form for each different incident

(use back of form to provide more information)

Joe Walsh for Congress Committee, Inc.
218 Barron Blvd. – Grayslake, IL 60030 – 847.752.8155
Fax: 847.307.7972
Email: nick@walshforcongress.com

Incident Report – November 2, 2010 General Election
(please email, deliver or fax no later than 2 days after you receive this)
(please print)
Person Reporting ___________________________
Residence Address __________________________
Phone: Day ____________ Evening ___________
Address of incident _________________________

Cellular: _____________ Pager: ______________
Email: ___________________________________
County: ________Township or Ward __________
Precinct #_______Time of incident _______am/pm

Did the Election Judges ALWAYS check the list of early and absentee voters before issuing a ballot? ___
If not, did they do so after somebody reminded them? ____ Explain below or on reverse side.
Describe incident ___________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Resolution of incident _______________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Offender __________________________________
Role in pollingplace _________________________
Residence Address __________________________

Day Phone ___________________
Evening Phone ________________

Offender _________________________________
Role in pollingplace _________________________
Residence Address __________________________

Day Phone ___________________
Evening Phone ________________

Voter Involved _____________________________
Residence Address __________________________

Day Phone ___________________
Evening Phone ________________

Voter Involved _____________________________
Residence Address __________________________

Day Phone ___________________
Evening Phone ________________

Voter Involved _____________________________
Residence Address __________________________

Day Phone ___________________
Evening Phone ________________

Witness ___________________________________
Residence Address __________________________

Day Phone ___________________
Evening Phone ________________

Witness ___________________________________
Residence Address __________________________

Day Phone ___________________
Evening Phone ________________