Preference Form/application
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Client’s preference (check the box only in 1. or 2.)
OFFICIAL USE ONLY (check all that apply)
If you do not check any box, it will be considered that you chose not to
[Note: Only a client who is eligible can decline or accept an
opportunity to register or update a record on his or her behalf]
register or update your voter registration at this time.
1. If you are not registered to vote where you live now,
�
New services/assistance
1. Client applied for:
would you like to apply to register to vote today?
�
�
Renewal of services/assistance
Address change
�
�
In person
By phone
2. How client applied:
Yes
No, I decline.
�
�
At home
Online/web service
2. If you are registered to vote where you live now, would you
�
like to update your voter registration record?
Submitted registration application.
3. Client:
�
Was sent form/application on ___/___/___(date).
Yes
No, I decline.
�
Did not complete application/took form/application.
CLIENT
:
Preference form must be retained by agency for two years from dated
Name or identification number
Date
form (DS-DE 77-ENG; rev. 11-2011)
=======================Notice of Rights====================
Help:
If you would like help in filling out your voter registration application, we will help you. The decision whether to seek or
accept help is yours. You may fill out the voter registration application in private.
Benefits:
If you are applying for public assistance from this agency, applying to register, or declining to register to vote will not
affect the amount of assistance you will be provided by this agency.
Privacy:
Your decision not to register or update your record and the location where you applied to register or update your voter
registration record is confidential and may only be used for voter registration purposes.
Formal Complaint:
If you believe someone has interfered with either your right to apply to register or to decline to register to
vote, your right to privacy in deciding whether to apply to register to vote, or your right to choose your own political party or other
political preference, you may file a complaint with: Florida Secretary of State, Division of Elections, NVRA Administrator, R.A.
Gray Building, 500 S. Bronough Street, Tallahassee, Florida 32399-0250. Forms for filing a complaint are available at
or call 1-850-245-6200.
[Authority: National Voter Registration Act (42 U.S.C. 1973gg); sections 97.023, 97.058, and 97.0585, F.S.]
To Register to Vote in Florida, You Must:
Be a U.S. citizen (a lawful permanent resident cannot register or vote)
Be at least 18 years old (you may pre-register if you are at least 16 years old although you cannot vote
until you are 18 years old)
Be a Florida resident
Have had your right to vote restored if you have ever been convicted of a felony
Have had your right to vote restored if a court has ever declared you to be mentally incapacitated as to
your right to vote.
If you do not meet these requirements, you are not eligible to register.
------------------------------------------------------------------------------------------------------------
You Can Register to Vote at:
Any Supervisor of Elections’ office
Any driver’s license office or tax collector’s office that issues driver’s licenses
Any voter registration agency (that is, any public assistance office, any office that provides services for
persons with disabilities, any center for independent living, any armed forces recruitment office or any
public library)
The Division of Elections (Florida Department of State)
----------------------------------------------------------------------------------------------------------
You Can Hand-in or Mail a Completed Application to
Any of the Locations Listed Above
If mailing, mail with sufficient postage to:
Division of Elections
R.A. Gray Building
500 S. Bronough Street
Tallahassee, Florida 32399-0250
(contact information: 850-245-6200; )
Your Supervisor of Elections will contact you if your application is incomplete, denied, or a duplicate.
Once you are registered, you will receive a voter information card.
***************************Turn Page Over for Registration Application*********************
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