Voter Registration Application Before completing this form, review the General, Application, and State specific instructions.

Are you a citizen of the United States of America? Yes No This space for office use only. Will you be 18 years old on or before election day? Yes No If you checked "No" in response to either of these questions, do not complete form. (Please see state-specific instructions for rules regarding eligibility to register prior to age 18.) Mr. Miss Last Name First Name Middle Name(s) Jr II 1 III Mrs. Ms. Sr IV Home Address Apt. or Lot # City/Town State Zip Code 2

Address Where You Get Your Mail If Different From Above City/Town State Zip Code 3

Date of Birth Telephone Number (optional) ID Number - (See item 6 in the instructions for your state) 4 5 Month Day Year 6 Choice of Party Race or Ethnic Group 7 (see item 7 in the instructions for your State) 8 (see item 8 in the instructions for your State)

I have reviewed my state's instructions and I swear/affirm that: ■ I am a United States citizen ■ I meet the eligibility requirements of my state and subscribe to any oath required. 9 Please sign full name (or put mark) ■ The information I have provided is true to the best of my knowledge under penalty of perjury. If I have provided false information, I may be fined, imprisoned, or (if not a U.S. Date: citizen) deported from or refused entry to the United States. Month Day Year If you are registering to vote for the first time: please refer to the application instructions for information on submitting copies of valid identification documents with this form.

Please fill out the sections below if they apply to you. If this application is for a change of name, what was your name before you changed it?

Mr. Miss Last Name First Name Middle Name(s) Jr II A III Mrs. Ms. Sr IV

If you were registered before but this is the first time you are registering from the address in Box ,2 what was your address where you were registered before? Street (or route and box number) Apt. or Lot # City/Town/County State Zip Code B

If you live in a rural area but do not have a street number, or if you have no address, please show on the map where you live.

■ Write in the names of the crossroads (or streets) nearest to where you live. NORTH  ■ Draw an X to show where you live. ■ Use a dot to show any schools, churches, stores, or other landmarks near where you live, and write the name of the landmark. C Example ● Grocery Store Woodchuck Road Route #2 Route Public School ● X

If the applicant is unable to sign, who helped the applicant fill out this application? Give name, address and phone number (phone number optional). D Mail this application to the address provided for your State. FOR OFFICIAL USE ONLY

FIRST CLASS STAMP NECESSARY FOR MAILING General Instructions Who Can Use this Application How to Submit Your Application If you are a U.S. citizen who lives or has an address Mail your application to the address listed under within the United States, you can use the application in your State in the State Instructions. Or, deliver the this booklet to: application in person to your local voter registration • Register to vote in your State, office. The States that are required to accept the • Report a change of name to your voter registration national form will accept copies of the application office, printed from the computer image on regular paper • Report a change of address to your voter registration stock, signed by the applicant, and mailed in an office, or envelope with the correct postage. • Register with a political party. First Time Voters Who Register by Mail Exceptions If you are registering to vote for the first time in Please do not use this application if you live outside your jurisdiction and are mailing this registration the United States and its territories and have no home application, Federal law requires you to show proof (legal) address in this country, or if you are in the of identification the first time you vote. Proof of military stationed away from home. Use the Federal identification includes: Postcard Application available to you from military • A current and valid photo identification or bases, American embassies, or consular offices. • A current utility bill, bank statement, government check, paycheck or government document that New Hampshire town and city clerks will accept this shows your name and address. application only as a request for their own absentee Voters may be exempt from this requirement if they voter mail‑in registration form. submit a COPY of this identification with their mail in North Dakota does not have voter registration. voter registration form. If you wish to submit a COPY, Wyoming law does not permit mail registration. please keep the following in mind: • Your state may have additional identification How to Find Out If You Are Eligible to Register to requirements which may mandate you show Vote in Your State identification at the polling place even if you meet Each State has its own laws about who may register and the Federal proof of identification. vote. Check the information under your State in the State Instructions. All States require that you be a United • Do not submit original documents with this States citizen by birth or naturalization to register to vote application, only COPIES. in federal and State elections. Federal law makes it illegal to falsely claim U.S. citizenship to register to vote in any If You Were Given this Application in a State federal, State, or local election. You cannot be registered Agency or Public Office to vote in more than one place at a time. If you have been given this application in a State How to Fill Out this Application agency or public office, it is your choice to use the Use both the Application Instructions and State application. If you decide to use this application to Instructions to guide you in filling out the application. register to vote, you can fill it out and leave it with • First, read the Application Instructions. These the State agency or public office. The application instructions will give you important information that will be submitted for you. Or, you can take it with applies to everyone using this application. you to mail to the address listed under your State in the State Instructions. You also may take it • Next, find your State under the State Instructions. with you to deliver in person to your local voter Use these instructions to fill out Boxes 6, 7, and registration office. refer to these instructions for information about Note: The name and location of the State agency voter eligibility and any oath required for Box 9. or public office where you received the application When to Register to Vote will remain confidential. It will not appear on your Each State has its own deadline for registering to vote. application. Also, if you decide not to use this Check the deadline for your State on the last page of application to register to vote, that decision will this booklet. remain confidential. It will not affect the service you receive from the agency or office.

1 Revised 03/01/2006 Application Instructions Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. However, state specific instructions may provide additional information on eligibility to register to vote prior to age 18.

Box 1 — Name Box 7 — Choice of Party Put in this box your full name in this order — Last, In some States, you must register with a party if you First, Middle. Do not use nicknames or initials. want to take part in that party’s primary election, Note: If this application is for a change of name, please caucus, or convention. To find out if your State requires tell us in Box A (on the bottom half of the form) your this, see item 7 in the instructions under your State. full name before you changed it. If you want to register with a party, print in the box the Box 2 — Home Address full name of the party of your choice. Put in this box your home address (legal address). Do not put your mailing address here if it is different from If you do not want to register with a party, write “no your home address. Do not use a post office box or party” or leave the box blank. Do not write in the word rural route without a box number. Refer to state‑specific “independent” if you mean “no party,” because this instructions for rules regarding use of route numbers. might be confused with the name of a political party in your State. Note: If you were registered before but this is the first Note: If you do not register with a party, you can still time you are registering from the address in Box 2, vote in general elections and nonpartisan (nonparty) please tell us in Box B (on the bottom half of the form) primary elections. the address where you were registered before. Please give us as much of the address as you can remember. Box 8 — Race or Ethnic Group A few States ask for your race or ethnic group, in order Also Note: If you live in a rural area but do not have a to administer the Federal Voting Rights Act. To find street address, or if you have no address, please show out if your State asks for this information, see item 8 where you live using the map in Box C (at the bottom in the instructions under your State. If so, put in Box 8 of the form). the choice that best describes you from the list below: • American Indian or Alaskan Native Box 3 — Mailing Address • Asian or Pacific Islander If you get your mail at an address that is different from • Black, not of Hispanic Origin the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in • Hispanic Box 3 an address where you can be reached by mail. • Multi‑racial • White, not of Hispanic Origin Box 4 — Date of Birth • Other Put in this box your date of birth in this order — Month, Day, Year. Be careful not to use today’s date! Box 9 — Signature Review the information in item 9 in the instructions Box 5 — Telephone Number under your State. Before you sign or make your mark, Most States ask for your telephone number in case make sure that: there are questions about your application. However, you do not have to fill in this box. (1) You meet your State’s requirements, and (2) You understand all of Box 9. Box 6 — ID Number Federal law requires that states collect from each Finally, sign your full name or make your mark, and registrant an identification number. You must refer to print today’s date in this order — Month, Day, Year. your state's specific instructions for item 6 regarding If the applicant is unable to sign, put in Box D the information on what number is acceptable for your name, address, and telephone number (optional) of the state. If you have neither a drivers license nor a social person who helped the applicant. security number, please indicate this on the form and a number will be assigned to you by your state.

2 Revised 03/01/2006 State Instructions

Mailing address: more days before an election are Mailing address: State Board of Elections considered on time even if received Elections Division 2329 S. MacArthur Boulevard after the deadline. Office of the Secretary of State Springfield, IL 62704 Lucas Building-1st Floor *If you fail to meet the voter 321 E. 12th Street Indiana registration deadlines above you Des Moines, IA 50319 can register and vote by following Updated: 03-01-2006 the guidelines for election day Kansas registration. You can find these Registration Deadline — 29 days on the Iowa Secretary of State’s Updated: 02-01-2016 before the election. website: www.sos.state.ia.us/pdfs/ elections/EDRbrochure.pdf. Registration Deadline — 6. ID Number. Your state voter ID Postmarked or delivered 21 days number is your ten digit Indiana 6. ID Number. Your ID number is before the election issued driver's license number. If you your Iowa driver's license number do not possess an Indiana driver's (or Iowa non-driver identification 6. ID Number. Your completed license then provide the last four number) if you have one, if not voter registration form must digits of your social security number. then the last four digits of your contain your state issued driver's Please indicate which number was social security number. The ID license number or nondriver's provided. (Indiana Code 3-7-13-13) number you provide will be identification card number. If you 7. Choice of Party. Leave blank. verified with the Iowa Department do not have a driver's license or 8. Race or Ethnic Group. Leave of Transportation or the Social nondriver's identification card, you blank. Security Administration. must include the last four digits 9. Signature. To register in Indiana 7. Choice of Party. You may, but of your social security number. If you must: do not have to, register with a party you do not have a driver's license • be a citizen of the United States in advance if you want to take part or a nondriver's identification card • have resided in the precinct at least in that party’s primary election. or social security number, please 30 days before the next election You may change or declare a party write "NONE" on the form. A • be at least 18 years of age on the affiliation at the polls on primary unique identifying number will be day of the next general election election day. assigned by the State. The number • not currently be in jail for a 8. Race or Ethnic Group. Leave you provide will be used for criminal conviction blank. administrative purposes only and 9. Signature. To register in Iowa will not be disclosed to the public. Mailing address: you must: (KSA 25-2309). Election Division • be a citizen of the United States 7. Choice of Party. You must Office of the Secretary of State • be a resident of Iowa register with a party if you want to 302 West Washington Street, • be at least 17-1/2 years old (you take part in that party’s primary Room E-204 must be 18 to vote) election, caucus, or convention. Indianapolis, IN 46204-2743 • not have been convicted of a 8. Race or Ethnic Group. Leave felony (or have had your rights blank. Iowa restored) 9. Signature. To register in Kansas • not currently be judged by a you must: Updated: 03-28-2008 court to be "incompetent to vote" • be a citizen of the United States • not claim the right to vote in • be a resident of Kansas Registration Deadline — Must be more than one place • be 18 by the next election delivered by 5 p.m. 10 days before • give up your right to vote in any • have provided a document, the election, if it is a state primary other place or copy thereof, demonstrating or general election; 11 days before United States citizenship within 90 all others.* Registration forms days of filing the application with which are postmarked 15 or 8 State Instructions the secretary of state or applicable (10) an American Indian card 9. Signature. To register in county election officer with KIC classification issued Kentucky you must: • have completed the terms of your by the U.S. Department of • be a citizen of the United States sentence if convicted of a felony; Homeland Security; • be a resident of Kentucky a person serving a sentence for a (11) a final adoption decree • be a resident of the county for at felony conviction is ineligible to vote showing the applicant's name least 28 days prior to the election date • not claim the right to vote in any and United States birthplace; • be 18 years of age on or before other location or under any other (12) an official U.S. military the next general election name record of service showing • not be a convicted felon or if you • not be excluded from voting by a the applicant's United States have been convicted of a felony, court of competent jurisdiction birthplace; your civil rights must have been • acceptable documents (13) an extract from a U.S. restored by executive pardon demonstrating United States hospital record of birth created • not have been judged “mentally citizenship as required by K.S.A. at the time of the applicant's incompetent” in a court of law § 25-2309(l) include the following: birth indicating the applicant's • not claim the right to vote (1) a driver's license or non- United States birthplace. anywhere outside Kentucky driver state identification card If one does not possess any of indicating on its face that the the listed documents, the person Mailing address: holder has provided satisfactory may alternatively prove his or her State Board of Elections proof of United States citizenship through the process 140 Walnut Street citizenship; described in K.S.A. § 25-2309(m). Frankfort, KY 40601-3240 (2) a birth certificate indicating birth in the United States; Mailing address: Louisiana (3) pertinent pages of a valid of Secretary of State expired United States passport 1st Floor, Memorial Hall Updated: 08-14-2012 identifying the applicant and the 120 SW 10th Ave. applicant's passport number; Topeka, KS 66612-1594 Registration Deadline — 30 days (4) a naturalization document before the election. indicating United States Kentucky citizenship. 6. ID Number. You must provide (5) A document issued by the Updated: 03-01-2006 your Louisiana driver’s license federal government pursuant number or Louisiana special to the Immigration and Registration Deadline — 29 days identification card number, if Naturalization Act of 1952, and before the election. issued. If not issued, you must amendments thereto, indicating provide at least the last four digits United States citizenship; 6. ID Number. Your full social of your social security number, (6) a Bureau of Indian Affairs security number is required. It is if issued. The full social security card number, tribal treaty card used for administrative purposes number may be provided on a number, or tribal enrollment only and is not released to the voluntary basis. If the applicant number; public (KRS 116.155). No person has neither a Louisiana driver’s (7) a consular report of birth shall be denied the right to register license, a Louisiana special abroad of a citizen of the United because of failure to include social identification card, or a social States; security number. security number, the applicant (8) a certificate of citizenship 7. Choice of Party. You must shall attach one of the following issued by the U.S. Citizenship register with a party if you want to items to his application: (a) a and Immigration Services; take part in that party’s primary copy of a current and valid photo (9) a certificate of report of birth election, caucus, or convention. identification; or (b) a copy of a issued by the U.S. Department of 8. Race or Ethnic Group. Leave current utility bill, bank statement, State; blank. government check, paycheck, or other government document that

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