P4-03 2022 SLD Verification Form

OMB Number: 0607-0988
Expiration Date: XX-XX-2024

PHASE 4 (POST 2020 CENSUS) STATE LEGISLATIVE DISTRICT BOUNDARY VERIFICATION FORM FOR _______________________

(state name)

I have reviewed the state legislative district boundaries, identifying numbers (and names if applicable). I verify that the boundaries, numbers, and names are correct as shown.

State Legislative District – Upper Chamber (Senate – SLDU)

State Legislative District – Lower Chamber (House – SLDL)

I have reviewed the state legislative district boundaries, identifying numbers (and names if applicable). I verify that the boundaries are correct as shown, except for the following block assignments specified below:

State Legislative District – Upper Chamber (Senate – SLDU)

State Legislative District – Lower Chamber (House – SLDL)

I have reviewed the state legislative district boundaries, identifying numbers (and names if applicable). I verify that the boundaries are correct as shown, except for the identified block assignments. In lieu of specifying the incorrect block assignments, codes, or names, we are providing corrections by sending a new block equivalency file via e-mail to [email protected].

State Legislative District – Upper Chamber (Senate – SLDU)

State Legislative District – Lower Chamber (House – SLDL)

Date ___________ Signature ____________________________________

Name ___________________________________________________________

Title ___________________________________________________________

Address ___________________________________________________________

City _______________________ State ___________ Zip Code __________

E-mail ___________________________________________________________

Fax ___________________________________________________________

Plan Type (SLDU/SLDL)	County (code)	Census Tract	Census Block	Incorrect District #	Correct District #

Please return this form by e-mail to [email protected] or by FAX at 301-763-4348