Form Aw5-15(A) Confidential Voter Registration Form And Early Voting Ballot Application
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1
2AW5-15(a) 6/2012
Prescribed by Secretary of State
Section 84.0021, Texas Election Code
Confidential Voter Registration Form and Early Voting Ballot Application
(FOR ADDRESS CONFIDENTIALITY PROGRAM PARTICIPANTS ONLY)
I REQUEST AN EARLY VOTING BALLOT FOR ALL ELECTIONS IN WHICH I AM ELIGIBLE TO VOTE AND THAT IS CONDUCTED BY YOUR OFFICE.
I UNDERSTAND THAT IF I WANT TO RECEIVE A BALLOT FROM AN ENTITY WHOSE ELECTION YOUR OFFICE IS NOT CONDUCTING, I MUST APPLY AT
THEIR OFFICE IN PERSON.
Use blue or black ink – please print clearly.
1
.
Last Name (Include Suffix if any – Jr, Sr, III)
First Name
Middle Name (if any)
Former Name (if any)
2.
Confidential Mailing Address (Assigned by Office of the Texas Attorney General)
City:
State: TX
Zip:
3.
4.
5.
Texas Address Confidentiality Authorization Number
Date of Birth (
Gender
MM / DD / YYYY)
(Optional)
(Assigned by Office of the Attorney General
)
Male
/
/
Female
6.
Texas Driver’s License Number or Texas Personal
If no Texas Driver’s License or Personal Identification,
Identification Number
give last 4 digits of your Social Security Number.
(Issued by the Dept. of Public Safety)
XXX – XX –
I have not been issued a Texas Driver’s License/Personal Identification Number or Social Security Number.
7.
Telephone (Optional)
Email Address (Optional)
(
)
–
8.
Party Preference (Primary Election Only) – Fill in ONE box
Republican
Democrat
None
10.
9.
ACKNOWLEDGMENT OF CONFIDENTIAL STATUS
I understand that giving false information to procure a
Initial here _______ to acknowledge your status as an address confidential
voter registration is perjury and a crime under state
program participant. “I swear or affirm that I am a certified participant or
and federal law. Conviction of this crime may result in
eligible household member of a certified participant in an address
imprisonment up to 180 days, a fine up to
$2,000 or both.
confidentiality program administered by the Texas Attorney General as
PLEASE READ ALL THREE STATEMENTS TO AFFIRM
described in Chapter 56, Texas Code of Criminal Procedure. I understand that
BEFORE SIGNING.
by completing this application, it is my responsibility to cancel my voter
registration in any county in which I may have been registered to vote, if my
I affirm that I
voter registration was not previously canceled. It is also my responsibility to
·
cancel any confidential application for ballot by mail that was filed in a county of
am a resident of this county and U.S. Citizen;
·
previous residence. I understand that I am requesting a ballot by mail for every
have not been finally convicted of a felony or if a felon I have
election conducted by the early voting clerk within the boundaries of the
completed all of my punishment including any term of
territories in which I reside until my address confidential certificate expires
incarceration, parole, supervision, period of probation, or I have
(three (3) years after the application is submitted) or your office receives notice
been pardoned; and
·
that I am no longer in the program or my ballot by mail has been returned as
have not been determined by a final judgment of a court
undeliverable, whichever occurs first.”
exercising
probate
jurisdiction
to
be
totally
mentally
incapacitated or partially mentally incapacitated without the right
to vote.
(For Office Use Only)
X
_________________________________________
Voter is qualified to vote in the following jurisdictions indicated by the
Signature of Applicant or Agent and Relationship to Applicant or Printed
verbal physical description of their residence:
Name of Applicant if Signed by Witness.
District Type
District Code
District Type
District Code
___/___/___
____________
___________
__________
____________
Date
If additional districts, attach list to form.
Date Address Confidential Certificate expires: _____/_____/______
REMEMBER TO SIGN AND DATE ITEM 10.
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