Form Vr-154i - Application For Maryland Challenge Of Address And/or Name

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Motor Vehicle Administration
VR-154i (01-09)
6601 Ritchie Highway, N.E.
Glen Burnie, Maryland 21062
Internet Version
Application for Maryland Change of Address and/or Name
Please complete in ink. All applicants must complete Section A. Complete Section B to apply to register to vote in Maryland. If you are already
registered to vote in Maryland, you can use Section B to indicate that you do not want your voter registration name/address updated or to change
your party affiliation. For additional instructions, see back of form.
Present (old) information
Enter new or changed information only
Copy from your driver’s license and/or registration card
Driver’s
Driver’s
License No.:
License No.:
First:
Middle:
Last:
Title (Jr., Sr., etc.):
First:
Middle:
Last:
Title (Jr., Sr., etc.):
Name:
Name:
Sex:
Sex:
Height:
Weight:
Race:
Date of Birth:
Height:
Weight:
Race:
Date of Birth:
Resident
Resident
Address
Address
City:
County:
State:
City:
:
State:
Zip:
County
Zip:
Title Number:
Tag Number:
Sticker Number:
Check reason for changing your name:
Error
Marriage
Divorce
Common Law
Reassume previously used surname
Court order
Certification: I hereby certify, under penalty of perjury, that the statements made on this form are true and correct to the best of my knowledge, information, and belief.
Full Signature
Date:
(required):
X
Affidavit to reassume previously used name or for common law name change
I am requesting that my previous name be changed from:
I am requesting that my previous name be changed to:
First:
Middle:
Last:
Title (Jr., Sr., etc.):
First:
Middle:
Last:
Title (Jr., Sr., etc.):
I hereby certify, under penalty of perjury, to using this name openly, consistently, and without fraudulent intent.
New Name Signature (required):
Date:
1
If you are already registered to vote in Maryland, the information in Section A will automatically update your voter registration information.
Check here if you do not want your voter registration updated.
If you are already registered to vote in Maryland and you only want to change your party affiliation, complete Items 3, 9, 13, and 14.
If you are NOT registered to vote in Maryland, and you would like to apply to register to vote, complete Items 2 - 14.
Check boxes that apply and complete Items 4-14:
2
3
Will you be at least 18 years old or older on or by the next General Election?
Yes
No
New Registration
Party Affiliation Change
Are you a U.S. citizen?
Yes
No
If you answer NO to either question, do not complete this form.
Name Change
Address Change
4
Mailing address (if different
from residence address
above in section A):
Month
Day
Year
5
6
7
Birth
Daytime Phone:
Sex:
Male
Female
Date:
8
Social Security Number:
(Voluntary. See Instructions in section D):
9
Party (check one):
Democrat
Republican
Green
Libertarian
Independent
Constitution
Unaffiliated (decline to join a party)
Other – Specify:
11
10
Check here if you would like information on polling place assistance for elderly,
Check here if you would like information on working as an election
disabled, or voters unable to write or to read the ballot.
judge for your county board of elections.
12
Under penalty of perjury, I hereby swear or affirm: I am a US citizen • I am a Maryland resident • I will be at least 18 years old or older by the next General Election • I am not
under guardianship for mental disability • I have not been convicted of buying or selling votes • I have not been convicted of a felony, or if I have, I have completed serving a
court-ordered sentence of imprisonment, including any term of parole or probation for the conviction. The information in Section B of this application is true to the best of my
knowledge, information, and belief.
14
13
Full Signature (required)
Date
DO NOT WRITE IN SPACE BELOW
CONTROL NUMBER
REG. CODE
CLERK’S INITIALS
Name on Last
Last Name
Title (Jr., Sr., etc.)
First Name
Middle Initial
A
MC
Registration
(if applicable):
VOTER ID
Address on Last
Street Number
Street Name
City or Town
State
Zip Code
B
Registration
DISTRICT PRECINCT
WARD
MONTH
DAY
YEAR
(if applicable):
For more information, please call: 1-800-638-8347 (touch tone calls only), 1-800-950-1MVA (1682) (to speak with a customer service representative),
From Out-of-State: 1-301-729-4550, TTY for the hearing impaired: 1-800-492-4575. Visit our website at:
White Copy - Board of Elections
Canary Copy - MVA
Pink Copy - Customer

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