Mail-In Voter Registration Form - State Of Utah

State of Utah Mail-in Voter Registration Form

Voter Instructions - You can also register to vote online at voter.utah.gov

NOTICE:

Voter registration records are considered

You may use this form to:

public under Utah Code

63G-2-301, excluding driver

 Register to vote in Utah

license or identification card numbers, Social Security

 Change your name or address on your voter registration record

numbers, and email addresses.

 Affiliate with a party or change your party affiliation

The portion of a voter registration form that lists a

To register to vote in Utah, you must:

person’s date of birth is a private record, the use of

 Be a citizen of the United States

 Have resided in Utah at least 30 days immediately before the next election

which is restricted to government officials, government

 Be at least 18 years old on or before the next election

employees, political parties or certain other persons.*

Mail-in registration instructions:

 Complete all required information; if not applicable write “N/A.”

 If you have registered to vote with a different name or address, complete the change of information section.

 One of the following is required: a Utah Driver License number, a Utah State Identification number, or the last four digits of your Social Security

number. If you do not have a Utah Driver License or a Utah State Identification card, please write “None” in the space designated for a Utah Driver

License or Utah State Identification and fill in the last four digits of your Social Security number.

 Read the voter declaration and citizenship affidavit and sign and date below.

Deadline for submitting this form:

 By Mail: This form must be postmarked at least 30 days before an election to be eligible to vote in that election (see the back of this form)

 Walk In: This form must be delivered in person to your county clerk at least 8 days before the election to be eligible to vote in that election

Please note:

 If you are qualified and the information on your form is complete, your county clerk will mail confirmation of your registration to you.



*If you believe that disclosure of any information contained in this voter registration form to a person other than a government official

or government employee is likely to put you or a member of your household’s life or safety at risk, or to put you or a member of your

household at risk of being stalked or harassed, you may apply to the lieutenant governor or your county clerk to have your entire voter

registration record classified as private.

 You must present valid voter identification to the poll worker before voting, which must be a valid form photo identification that shows your name

and photograph, or (2) two different forms of identification that show your name and current address.

 For more information contact your county clerk (see the back of this form) or the Lieutenant Governor’s Office at vote.utah.gov or 1-800-995-VOTE.

In accordance with Utah code section 20A-2-401, the penalty for willfully causing, procuring, or allowing yourself to be registered to vote if you know you are not entitled to vote is up to

one year in jail and a fine of up to $2,500.

 Yes  No

Reason(s) for completing this form (optional)

Are you a citizen of the United States?

 New Registration

 Party Affiliation Change

 Yes  No

Will you be at least 18 years on or before election day?

 Address Change

 Name Change

Qualifications: If you check no in response to either of these questions do not complete this form

Address change

Name change

Last Name

First Name

Middle Name

Name at Birth (if different than above)

Date

Place of Naturalization (if applicable)

Physical Address (required, principal place of residence, no P.O. Box)

County

City

State

Zip Code

Mailing Address (if different from physical)

County

City

State

Zip Code

Phone Number (optional)

Date of Birth (required, month/day/year)

Place of Birth (required, state or county)

Last Four Digits of Social Security #

Utah Driver License or Identification number

Political Party Affiliation: (optional)

 Constitution  Democratic  Independent American  Libertarian

 Republican

Email address (optional)

 Unaffiliated (no party preference)  Other ____________ (specify)

 Yes

 No

Would you like to be a permanent absentee voter and receive your ballot by mail on an

I am a person with a disability (optional)

 Yes

 No

on-going basis? (read declaration)

 Never registered in State of Utah

If previously registered and/or changing personal information, also fill out this section.

Name on Previous Registration_________________ Address on Previous Registration______________________________________ City___________ State _____ Zip__________

Read and Sign below

Voter Declaration: I do swear (or affirm), subject to penalty of law for false statements, that the information contained in this form is true and that I am a citizen of the United States

and a resident of the State of Utah, residing at the above address. I will be at least 18 years old on or before the next election and I will have resided in Utah for 30 days immediately

before the next election. I am not a convicted felon currently incarcerated for commission of a felony.

Citizenship Affidavit: I hereby swear and affirm, under penalties for voting fraud set forth above in Utah Code Section 20A-2-401, that I am a citizen and that to the best of my

knowledge and belief the information above is true and correct.

Vote By-Mail (only if requested): I am a qualified elector, residing at the address above and I am applying for an official absentee ballot to be sent to me and voted by me at each

election in which I am eligible to vote.

Signature

Date (Month/Day/Year)

Type of ID

Voting Precinct

Voting ID #

Type: By Mail

Form Date: 03/12

OFFICE USE ONLY