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.
Last Name (Include Suffix if any – Jr, Sr, III)
Middle Name (if any)
Former Name (if any)
Confidential Mailing Address (Assigned by Office of the Texas Attorney General)
Texas Address Confidentiality Authorization Number
Date of Birth (
MM / DD / YYYY)
(Assigned by Office of the Attorney General
Texas Driver’s License Number or Texas Personal
If no Texas Driver’s License or Personal Identification,
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.
Email Address (Optional)
Party Preference (Primary Election Only) – Fill in ONE box
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
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.”
incapacitated or partially mentally incapacitated without the right
(For Office Use Only)
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.
If additional districts, attach list to form.
Date Address Confidential Certificate expires: _____/_____/______
REMEMBER TO SIGN AND DATE ITEM 10.