Withdrawal Of Colorado Voter Registration - Secretary Of State Approved Form

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Withdrawal of Colorado Voter Registration

For office use only

Voter ID Number: ________________________

If you are currently registered to vote in Colorado, you may use this form to withdraw your voter

Date Stamp:

registration. You must fill out all fields marked with an asterisk (*).

Mail, deliver, or scan and email your signed form to your county clerk and recorder (contact information is

available online at ) or to the Colorado Secretary of State's Office:

The Colorado Secretary of State - Elections Division

1700 Broadway, Suite 200

Denver, Colorado 80290

Public.Elections@sos.state.co.us

Your name as registered

Last name*

First name*

Middle name

Your identifying information

Your birthdate (MM/DD/YYYY)*

Your Colorado Driver's License or Colorado ID card number, without dashes

(required if you do not provide your registered home address below):

The last 4 digits of your Social Security Number

Your contact information as registered

Your registered home address (required if you did not provide a Colorado Driver's License or Colorado ID card number above)

Street address (No P.O. Boxes)

Apt. or Unit

City or Town

ZIP Code

Colorado County

Your phone number and email

Area code

Phone number

Email address

Sign or mark below

I affirm that the voter registration information provided above is true and accurate to my best knowledge. I hereby request withdrawal of my Colorado voter

registration, effective the date that this form is received by the County Elections Office. I understand that I will no longer be eligible to vote in the State of

Colorado unless I re-apply for registration.

Signature or Mark*

Date*

Witness Signature

Date

(If you are unable to sign, you must make a mark and a witness to the mark must

sign here).

Secretary of State Approved Form 7/18/12

[Section 1-2-601, C.R.S.]