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Indiana Voter Registration Application

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Indiana Voter Registration Application
Indiana Voter Registration Application
If Not Typed,
Please Print in Blue or Black Ink
INDIANA VOTER REGISTRATION APPLICATION
(VRG-7)
State Form 50504 (R5/12-05)
Indiana Election Commission
You can use this application to:
Apply to register to vote in Indiana or
Change your name and address on your voter registration record.
To register you must:
Be a citizen of the United States;
Be at least 18 years old on the day of the next general or municipal election;
Have lived in your precinct for at least 30 days before the next election (except for
certain military voters); and
Not currently be imprisoned after being convicted of a crime.
If you move:
You must transfer your registration whenever you move out of your precinct.
You may use this application to transfer your registration. You may mail or hand deliver
the completed application to your county registration office.
To complete this form:
FILL IN ALL THE BOXES THAT APPLY TO YOU IN BLUE OR BLACK INK
Box 4: Residence Address Type or print the address where you live (number, street,
apartment number, city/town, and ZIP code). If your address is a rural route or star route,
be sure to include the box number. If this address does not have a street number, draw a
map in Box 15.
Box 5: Mailing Address If this address is the same as Box 4, just print “SAME” in this box.
Box 6: Previous Voter Registration Address If you have been registered previously,
please list your most recent registration address.
Boxes 8 and 9: These questions are optional. Your application will be processed even if
you do not answer these questions.
Box 10: Identification Documentation If you are registering to vote in Indiana for the first
time, and you are sending this application by mail, you must provide identification
documentation. Identification may include a current and valid photo id, current utility bill,
bank statement, government check, paycheck, or government document that shows the
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
day, you will be asked for it the first time you vote.
Box 11:If you check “no” in response to the question in Box 11, you may not complete this
application.
Box 12: The question in Box 12 requires a person to be at least 18 years of age by the
next general or municipal election. If you check “no” in response to the question in Box 12,
you may not complete this application.
Box 13: Voter Identification Number In Box 13, you are required to provide your Indiana
driver’s license number as issued by the Indiana Bureau of Motor Vehicles. If you do not
have an Indiana driver’s license, provide the last four digits of your social security number.
If you do not have an Indiana driver’s license number, or a social security number, a voter
identification number will be assigned to you.
Box 14: If this is an application for a name change, provide your previous name in Box 14.
If you have not changed your name, skip this question.
Box 15: Skip this question if the address where you live has a street name and number
(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
residence is located. If you do not live in a house or other building, please draw a map that
shows where you usually sleep and the nearby streets.
Box 16: This application cannot be processed without the voter’s original signature
in this section. DO NOT FAX THIS FORM AFTER COMPLETING IT.
Registration Deadlines: In order to be processed for the next election, this application
must be postmarked or hand delivered to your county voter registration office no later than
29 days before the next election. If your county registration office receives this application
after that day, you will be unable to vote in the next election. If you miss this deadline, your
registration application will be processed when registration reopens. Some military voters
and their family members can register until noon on election day. Contact your county voter
registration office for information if you may qualify to do so.
Acknowledgment Notice: You will be sent a notice from your county voter registration
office that acknowledges receipt of your voter registration application. The notice informs
you whether your registration application was approved by the county voter registration
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
not received an acknowledgment notice within 30 days of filing this application you should
contact your county voter registration office.
Questions Call your county voter registration office or the Indiana Election Division for
assistance.
Indiana Election Division
302 West Washington Street, Room E204
Indianapolis, Indiana 46204-2743
Telephone: 317-232-3939 or Toll-free Indiana only: 800-622-4941
www.in.gov/sos/elections
[email protected]
1
Check boxes
that apply:
New registration
Address change (See Box 6)
Name change (See Box 14)
2
Indiana county where you live:
COUNTY
USE ONLY
Date processed Township/Precinct County Tracking Number
3
Gender
Female
Male
Last Name
First Name
Middle Name or Initial
Suffix
Jr. Sr. II III IV
4
Residence Address (No Post Office Boxes)
Apt. No.
City / Town
State
IN
Zip Code
5
Mailing Address, if different from Box 4, if same, print “SAME”
Apt. No.
City / Town
State
Zip Code
6
Previous Voter Registration Address
County
Apt. No.
City / Town
State
Zip Code
7
Date of Birth (mm/dd/yy)
8
Telephone number (If available)
9
E-mail (If available)
10
Are you including identification documentation
(See instructions for Box 10 above.)
Yes No
Voter Identification Number
11
Are you a citizen of the United States
of America
Yes No
12
Will you be at least 18 years of age on
or before election day
Yes No
13
Provide your 10-digit Indiana issued driver’s
license number. If you do not possess an
Indiana driver’s license, then provide the last
4 digits of your social security number here.
Driver’s License Number
Social Security Number
None
14
If you have changed your name, what was your name
before you changed it If you have not changed
your name, skip this question.
Last Name
First Name
Middle Name or Initial
Suffix
Jr. Sr. II III IV
I authorize my voter registration at any other address to be cancelled. I swear or affirm that:
I am a citizen of the United States.
I will be at least 18 years of age at the next general or municipal election.
I will have lived in my precinct for at least 30 days before the next election.
I am not currently in prison after being convicted of a crime.
All the above information and all other statements on this form are true.