Bhsf Form 2-L (Nf) - Medicaid Renewal Form For Nursing Home/group Home Care (Page 9 of 9) in pdf

USE THIS FORM TO: 1) register to vote 2) change your address 3) request a name change 4) change party affiliation

TO REGISTER TO VOTE AND BE ELIGIBLE TO VOTE YOU MUST: 1) be a United States citizen 2) be at least 17 years old to register but must be 18 years old to vote 3) not be under an order of

imprisonment for conviction of a felony 4) not be under a judgment of full interdiction or limited interdiction where your right to vote has been suspended 5) reside in the state and parish in which you seek

to register and vote.

INSTRUCTIONS FOR COMPLETING THIS FORM: All information except your signature should be printed clearly in ink, preferably black, or typed. Fill in all boxes that apply to you.

Box 1:Indicate whether you are a citizen of the United States of America. Indicate whether you will be 18 years of age on or before election day.

Box 2: Provide full name. Do not use initials for middle or maiden name.

Box 3: 'Residence Address' means the address where you live and are registering to vote. If you claim a homestead exemption, you must list the address of that residence. Do not use a post office box

for your 'Residence Address'. If you use a rural route and box number, draw a map in the space labeled 'Give Location.' Write in the names of the crossroads (streets) nearest to where you live. Draw an

X to show where you live. Use a dot to show any schools, churches, stores or landmarks near where you live and write the name of the landmark. Check the box provided if mail is not delivered to your

residence address by the post office. Complete 'Mailing Address' only if it is different from the 'Residence Address' or if mail is not delivered to your residence address.

Box 4: Provide your age.

Boxes 6 & 14: You must provide your Louisiana driver's license number, if issued. If not issued, you must provide at least the last four digits of your social security number, if issued. The full social

security number may be provided on a voluntary basis. If neither a social security number nor a Louisiana driver's license number has been issued, and this form is submitted by mail, and you are

registering to vote for the first time, in order to avoid additional identification requirements for first time voters, attach either a) a copy of a current and valid photo identification or b) a copy of a current

utility bill, bank statement, government check, paycheck, or other government document that shows your name and address.

Boxes 8, 12 & 13: The items 'race/ethnic origin', 'home phone' and 'daytime phone' are not required but are helpful.

Box 9: If you do not complete this item, your party affiliation will be listed as 'none', unless you are presently registered with a party affiliation and no change is being made today. If you are not registering

with a political party, circle ‘none’. The recognized political parties are Democrat, Green, Libertarian, Reform and Republican or you may specify any other party affiliation.

Box 18: If you are using this form to request a change of name, you must print the name to be changed here.

Box 19: Date and sign the card with your signature or mark.

If returned by mail, place in an envelope and mail to the appropriate registrar of voters at the address found on the reverse side of this card. If you have not been issued a social security number or

Louisiana driver's license number, you must mail the required documentation with your application. Your application or envelope must be postmarked 30 days prior to the first election in which you seek

to vote based on the residence listed on this application.

NOTE:1. If you decline to register to vote, this fact will remain confidential and will be used only for voter registration purposes. If you register to vote, the office where your application was submitted will

remain confidential and will be used only for voter registration purposes. 2. Your social security number will also remain confidential and is intended to be used for voter registration purposes only.

QUESTIONS? Call your Parish Registrar of Voters OR call the Department of State at 1¬800¬883¬2805 or (225) 922¬0900.

COMPLETE AND CHECK ALL APPLICABLE BOXES AND TEAR ALONG PERFORATED LINE BEFORE MAILING.

LOUISIANA MAIL VOTER REGISTRATION APPLICATION

OFFICIAL USE ONLY

FORM #04

COMP REG # __________________ Reg Type ________ Wd/ Dist_____ Pct______ In______ Out_____

1 Are you a citizen of the United States of America? YES

Will you be 18 years of age on or before election day YES

If you checked no in response to either of these questions, DO NOT COMPLETE THIS FORM.

2 NAME OF APPLICANT (PLEASE PRINT NAME)

GIVE LOCATION

LAST

First

FULL MIDDLE OR MAIDEN

3 RESIDENCE ADDRESSS

(MUST BE ADDRESS WHERE YOU CLAIM HOMESTEAD EXEMPTION, IF ANY)

HOUSE OR APT. NO. & STREET

CITY OR TOWN

STATE

ZIP

IF NO mail delivery to residential address,

MAILING ADDRESS IF DIFFERENT

check here:( )

4 AGE

5 DATE OF BIRTH

6 * SOCIAL SECURITY #

7 SEX (

8 ** RACE/ ETHNIC ORIGIN

(CIRCLE ONE)

CIRCLE ONE)

(CIRCLE ONE)

MONTH

DAY

YEAR

WHITE

BLACK

ASIAN

HISPANIC

MALE

FEMALE

AMER. INDIAN

YES #__________________________

OTHER: _________________________

9 PARTY AFFILIATION

10 APPLICANTS'S PLACE OF BIRTH

11 MOTHERS MAIDEN NAME

CIRCLE ONE)

DEM

GRN

LBT

RFM

REP

NONE

CITY OR TOWN

PARISH OR COUNTY

STATE

COUTNRY

OTHER (SPECIFY) ________________

12 ** HOME PHONE

13 ** DAYTIME PHONE

14 LA DRIVERS LICENSE / I.D. #

15 Will you require assistance at the polls?

(CIRCLE ONE)

(CIRCLE

ONE)

(

)

(

)

YES IF YES, GIVE REASON

YES #_____________________

16 LAST RESIDENCE ADRESS

17 PLACE OF REGISTRATION

18 FOMER REGISTERED NAME, IF APPLICABLE

ADDRESS

PARISH OR COUNTY

STATE

AFFIRMATION : I do hereby solemnly swear or affirm that I am a United States citizen, that I am at least 17 years old, that I am not currently under an order of imprisonment for conviction of a felony,

that I am not currently under a judgment of full interdiction or limited interdiction where my right to vote has been suspended, that I am a bona fide resident of this state and parish, and that the facts

given by me on this application are true to the best of my knowledge and belief. If I have provided false information, I may be subject to a fine of not more than $1,000 ($2,500 for subsequent offense)

or imprisonment for not more than 1 year.

19 SIGN YOUR NAME IN BOX AT RIGHT

DATE: _______________/_________/_________________

20 IF YOU ARE UNABLE TO SIGN YOUR NAME, TWO WITNESSES TO YOUR MARK MUST SIGN HERE

WITNESS SIGNATURE

* Last 4 digits of the social security number required if no LA driver's license issued; social security number is intended to be used for voter registration purposes only

Full # Optional

** OPTIONAL

LR-1M (REV. 1/11, 7/11) R.S. 18:104 FORM #04

Bhsf Form 2-L (Nf) - Medicaid Renewal Form For Nursing Home/group Home Care Page 9

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