Official Iowa Voter Registration Form

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Y e a r
Ye a r
IOWA Voter Registration Form
Official
Revised
01/01/08
You are required by law to provide your current and valid Iowa driver’s license or Iowa non-operator ID number.
1.
If you do not have an Iowa driver’s license/non-operator ID number, provide the last 4 digits of your Social Security Number.
Valid IA Driver’s License or IA Non-Operator ID Number
Last 4 Digits of Social Security Number
Check this box only if you DO NOT have a current and valid Iowa driver’s license/ID OR a Social Security Number.
E-mail (optional)
Daytime Phone (optional)
Date of Birth ( M o n t h / D a y / Ye a r )
Sex
Male
2.
/
/
(
)
Female
Last Name
First Name
Middle Name
Suffix ( Sr., Jr., etc.)
Name
3.
Street Address (include apt., lot, etc., if applicable)
Iowa County Where You Live
ZIP
City
State
A
If mail CANNOT be delivered to the address above, provide an alternate mailing address.
Alternate Mailing Address (include P.O. Box if applicable)
ZIP
State
City
B
If you DO NOT have a street address because you use a rural route address or you are homeless, describe where you live.
Description (include Township and Section Number if known)
Political Affiliation
4.
Parties:
Non-Party Political Organizations:
NOTE:
If you leave this
Check Only
Green
Democratic
section blank,your
ONE
registration will be
Libertarian
Republican
listed as “No Party”.
Box
No Party
5.
PREVIOUS REGISTRATION
(If you have ever been registered to vote before, complete this section.)
Your Name Then
Your Address Then
County
State
ZIP
City
Are you a citizen of the United States of America?
Yes
No
6.
Will you be 18 years of age on or before Election Day?
Yes
No
If you checked NO in response to either of these questions, DO NOT complete this form.
WARNING:
READ and SIGN
7.
I swear or affirm that:
If you sign this
● I am the person named above.
● I am a citizen of the United States.
form and you know
● I am at least 17 ½ years old.
● I live at the address listed above.
it is not true, you
● I am not currently judged by a court to be “incompetent to vote”.
can be convicted
● I do not claim the right to vote anywhere else.
of perjury and
● I have not been convicted of a felony (or have received a restoration of rights).
fined up to $7,500
and/or jailed for up
X
_______________________________________________
________________
to 5 years.
Signature
Date

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