HomeMy WebLinkAboutvoter registration application VOTER REGISTRATION FORMS
AVAILABLEHERE
This office has forms that you can fill out
to register to vote in Indiana.
If you live in Indiana and are not registered to vote
where you live now, and you want to register
(or change your registration record),
please take one of the forms.
If you cannot find a blank voter registration form in
this office, ask us to give you a form.
You must take the form with you and mail or deliver
the form to the voter registration office.
Applying to register or declining to register to vote
will not affect the assistance or service that you will
be provided by this office.
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Q : : -2 iINDIANA VOTER REGISTRATION APPLICATION (VRG -7)
State Form 50504 (R8/5 -12)
Indiana Election Commission
1 You can use this application to: Box 13: Voter Identification Number In Box 13, you are required to provide your Indiana
• Apply to register to vote in Indiana or drivel's license number as issued by the Indiana Bureau of Motor Vehicles. If you do not
• Change your name and address on your voter registration record. have an Indiana driver's license, provide the last four digits of your social security number.
To register you must: If you do not have an Indiana driver's license number, or a social security number, a voter I
• Be a citizen of the United States; identification number will be assigned to you.
• Beat least 18 years old on the day of the next general or municipal election; Box 14: If this is an application for a name change, provide your previous name in Box 14.
` • Have lived in your precinct for at least 30 days before the next election (except for If you have not changed your name, skip this question.
cer military voters); and Box 15: Skip this question if the address where you live has a street name and number
Not currently be imprisoned after being convicted of a crime. (such as 100 Maple Street). If you have a rural route or star route address, please draw a
simple map that shows the nearest crossroads or street intersection and where your
If you move: residence is located. If you do not live in a house or other building, please draw a map that
• You must transfer your registration whenever you move out of your precinct. shows where you usually sleep and the nearby streets.
• You may use this application to transfer your registration. You may mail or hand deliver Box 16: This application cannot be processed without the voter's original signature
the completed application to your county registration office. in this section. DO NOT FAX OR EMAIL THIS FORM AFTER COMPLETING IT.
To complete this form: Registration Deadlines: In order to be processed for the next election, this application
FILL IN ALL THE BOXES THAT APPLY TO YOU IN BLUE OR BLACK INK must be postmarked or hand delivered to your county voter registration office no later than
Box 4: Residence Address Type or print the address where you live (number, street, 29 days before the next election. If your county registration office receives this application
apartment number, city/town, and ZIP code). If your address is a rural route or star route, after that day, you will be unable to vote in the next election. If you miss this deadline, your
be sure to include the box number. If this address does not have a street number, draw a registration application will be processed when registration reopens. Some military voters
map in Box 15. and their family members can register until noon on election day. Contact your county voter
Box 5: Mailing Address If this address is the same as Box 4, just print "SAME" in this box. registration office for information if you may qualify to do so.
Box 6: Previous Voter Registration Address If you have been registered previously, Acknowledgment Notice: You will be sent a notice from your county voter registration
please list your most recent registration address. office that acknowledges receipt of your voter registration application. The notice informs
Boxes 8 and 9: These questions are optional. Your application will be processed even if you whether your registration application was approved by the county voter registration
you do not answer these questions. office. The notice may identify where you can vote. If your registration application is
incomplete, you may be contacted and asked to provide additional information. If you have
Box 10: Identification Documentation If you are registering to vote in Indiana for the first not received an acknowledgment notice within 30 days of filing this application you should
time, and you are sending this application by mail, you must provide identification contact your county voter registration office.
documentation. Identification may include a current and valid photo id, current utility bill, questions? Call your county voter registration office or the Indiana Election Division for
bank statement, govemment check, paycheck, or government document that shows the assistance.
name and address of the voter. You may include a copy of your identification with this
application. Do not mail an ORIGINAL copy of your document! If you do not provide
identification with this application or to the county voter registration office before election Indiana Election Division t
day, you will be asked for it the first time you vote. 302 West Washington Street, Room E204
Box 11:If you check "no" in response to the question in Box 11, you may not complete this Indianapolis, Indiana 46204 -2743 1
application. Telephone: 317 - 232 -3939 or Toll -free Indiana only: 800 - 622 -4941
Box 12: The question in Box 12 requires a person to be at least 18 years of age by the www.in.gov/sos/elections
next general or municipal election. If you check "no" in response to the question in Box 12,
ii you may not complete this application.
TfNot Typed, Please Print in Blue or Bieck ink
Check boxes ❑New registration Indiana county where you live: Date processed Township /Precinct County Tracking Number
1 ❑Address change (See Box 6) 2
that apply: COUNTY
USE ONLY
❑Name change (See Box 14)
Gender Last Name First Name Middle Name or Initial € Suffix
3 ❑ Female i i
❑ Male ! Jr. Sr. II III IV
i
Residence Address (No Post Office Boxes) Apt. No. City / Town i
4 i State 'Zip Code
•
•
IN
•
Mailing Address, if different from Box 4, if same, print "SAME" Apt. No. City / Town State Zip Code
5
•
Previous Voter Registration Address County f Apt. No. City / Town State ' Zip Code ,
6
•
•
7 Date of Birth (mm /dd /yy) 8 Telephone number (If available) E -mail (If available) Are you including identification documentation?
9 10 (See instructions for Box 10 above.)
❑ Yes ❑ No
Are you a citizen of the United States Will you be at least 18 years of age on Voter Identification Number !,
Provide
11 of Americ 12 or before election da your 10 di i Indiana issued driver's r-1 Driver's License Number
13 license number. If you do not possess an
❑Yes ❑ No ❑Yes ❑ No Indiana driver's license, then provide the l ❑ Social Security Number
4 digits of your social security number here. ❑ None
If you have changed your name, what was your name j Last Name i First Name Middle Name or Initial ' Suffix
14 before you changed it? If you have not changed 3 Jr. Sr. II III IV
your name, skip this question.
•
Map /Diagram: If your residence has no address, street number or name (such I authorize my voter registration at any other address to be cancelled. I swear or affirm that:
as 100 Maple Street), please draw a map showing where your residence is • 1 am a citizen of the United States. ,
located, include roads and landmarks. Otherwise, skip this question. • 1 will be at least 18 years of age at the next general or municipal election.
N • 1 will have lived in my precinct for at least 30 days before the next election.
• 1 am not currently in prison after being convicted of a crime.
• All the above information and all other statements on this form are true.
• 1 understand that ff I sign this statement knowing that it is not true I am committing perjury and
15
can be fined up to $10,000, jailed for up to three years or both. i
W E 16 Signature of Applicant Dat
If applicant is unable to fill out the application due to disability, the person who helped the applicant with this
application lists their name, address and telephone number in the box below. (Telephone number is optional.) 1
Name Address City/Town Telephone Number (optional)
S
50504