Form Fa-412 - Change Report Page 3
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NVRA-5 (Spanish)
ROPOSICIÓN DE EMPADRONAMIENTO
OFFER OF VOTER REGISTRATION
La cantidad de ayuda que esta oficina le va a proveer no será afectada por su
Applying to register to vote or declining to register to vote will not affect the
decisión de empadronarse para votar o de no empadronarse para votar.
amount of assistance that you will be provided by this agency.
Si usted no esta empadronado para votar donde usted actualmente vive,
If you are not registered to vote where you live now, would you like to apply to
¿le conviniera solicitar empadronamiento para votar hoy día aquí mismo?
register to vote today?
Yes
No
Si
No
IF YOU DO NOT MARK EITHER LINE, YOU WILL BE CONSIDERED TO
SI USTED NO MARCA NINGUNA DE LAS RESPUESTAS,
HAVE DECIDED NOT TO REGISTER TO VOTE AT THIS TIME.
SE CONSIDERARÁ QUE USTED HIZO LA DECISIÓN DE NO
EMPADRONARSE PARA VOTAR HOY DÍA.
If you would like help filling out the voter registration application form, we will
help you. The decision whether to seek or accept help is yours. You may fill
Si usted necesita ayuda para completar el formulario de solicitud de
out the application form in private. You may take the form with you and mail it
empadronamiento, nosotros estamos dispuestos a ayudarle. La decisión de
to the county recorder yourself or you may complete the registration here and
procurar o aceptar ayuda es suya. Se le permite completar el formulario de
deposit it in the box provided.
solicitud en privado. Usted tiene la opción de llevarse el formulario consigo y
regresarlo por correo al registrador del condado o usted puede completar su
If you choose to register to vote here, the information regarding the agency
empadronamiento aquí y depositarlo en el depósito que se proporciona.
where the registration took place will remain confidential and will be used only
for voter registration purposes. If you choose not to register to vote at this
Si usted se decide a empadronarse para votar, la información tocante la oficina
time, that information will remain confidential and will be used only for voter
donde se efectuó el empadronamiento permanecerá confidencial y se usará
registration purposes.
únicamente para los propósitos de empadronamiento de votantes.
Signature of Client (or initials of staff person)
Date
Firma del Cliente (o iniciales del miembro del personal)
Fecha
If you believe that someone has interfered with your right to register to vote
Si usted cree que alguien se ha impedido con su derecho de empadronarse
or to decline to register to vote, your right to privacy in deciding whether to
para votar o de no empadronarse para votar, su derecho a privacidad en
register to vote or in applying to register to vote, or your right to choose your
decidiendo de empadronarse o en solicitar empadronamiento para votar, o su
own political party or other political preference, you may file a complaint with:
derecho de seleccionar su propio partido político u otra preferencia política,
usted puede entablar su queja con:
State Election Director
Secretary of State’s Office
State Election Director
1700 West Washington
Secretary of State’s Office
Phoenix, Arizona 85007
1700 West Washington
Phoenix, Arizona 85007
FA-412 (10-17) - Page 3 of 3
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