The tally list shall be in the following form:

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We hereby certify the following to be a true tally of the votes for the candidates and offices shown herein cast at the election held on the day of , 20 in   election precinct, county, Arizona:

Names of offices Tally of votes

and candidates: (to be tallied in blocks Total vote

of five as:) (as:)

For

representative

in Congress:

John Doe //// Ninety-nine

We further certify that the total vote set opposite the name of each candidate is the total number of votes received by that candidate in the precinct of election.

(Leaving lines with designation, for signatures of clerks and board of election or tally board.)