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Iowa Voter Registration Form

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Iowa Voter Registration Form
Iowa Voter Registration Form
STATEOFIOWAOFFICIALVOTERREGISTRATIONFORM
InIowa,youarenotqualifiedtovoteifyouhavebeenconvictedofafelonyandhavenotreceiveda
restorationofvotingrights.YoumayapplytotheGovernortorestoreyourvotingrights.
1. AreyouacitizenoftheUnitedStates Yes No
2. Willyoube18yearsofageonorbeforeElectionDay Yes No

Ifyouanswered“No”toeitherofthesequestions,donotcompletethisform.
IAdriver’slicense#:

IAnonoperatorID#:
Last4digitsofSocialSecuritynumber:XXXXX
IdonothaveanIAdriver’slicense,nonoperatorID,orSocialSecuritynumber.
 DateofBirth(month,day,year)//


Gender Male Female 

Phoneand/orEmail(optional)
 Last
 First
 MiddleSuffix
StreetAddress
 (includeapt.,lot,etc.)

City Zip County
Ifhomelessoryoudonothaveanestablishedresidence,describewhereyoureside:
 Address/P.O.Box
City State Zip
Yournamewas
Youraddresswas
Yourcityandstatewere Yourzipwas
PoliticalParties: NoParty Democratic Republican
NonPartyPoliticalOrganizations: Green Libertarian
Iswearoraffirmunderpenaltyofperjurythat:
Iamthepersonnamedabove.
IamacitizenoftheUnitedStates.
Ihavenotbeenconvictedofafelony(orIhavereceivedarestorationofrights).
Iamatleast17½yearsold.
Iliveattheaddresslistedabove.
Iamnotcurrentlyjudgedbyacourttobe“incompetenttovote.”
Idonotclaimtherighttovoteanywhereelse.

SignatureDate
Revised 4/9/2014
Qualifications
IDNumber
ProvideyourIowa
driver’slicense,non
operatorIDnumber,
orthelast4digitsof
yourSocialSecurity
numberifyouhave
one.
YourName
Address
WhereYou
Live
WhereYou
ReceiveMail
(ifdifferent)
Previous
Voter
Registration
Information
Political
Affiliation
(checkonlyone)
Additional
Information
Dateofbirthand
genderarerequired.
WARNING
Ifyousignthis
formandyou
knowthe
informationis
nottrue,you
maybe
convictedof
perjuryand
finedupto
$7,500and/or
jailedforupto
5years.
RegistrantAffidavit
Iowa Voter Registration Form