Medicare Savings Programs Application/redetermination (Qmb, Slmb, Almb) (Page 6 of 6) in pdf

Medicare Savings Programs Application/redetermination (Qmb, Slmb, Almb) Page 6

DECLINING TO REGISTER TO VOTE

Connecticut General Statutes Sec. 9-23o states that state offices administering SNAP, Medicaid, WIC,

Temporary Family Assistance, and offices providing state-funded programs primarily engaged in providing

services to persons with disabilities must provide individuals with the opportunity to register to vote. This form

must be completed with each application for service or assistance, and with each recertification, renewal, or

change of address form relating to such service.

If you are not registered to vote where you live now, would you like to apply to register to vote here

today?

Yes

I decline because I am already registered

IF YOU DO NOT CHECK A BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER TO

VOTE AT THIS TIME.

Applying to register or declining to register will not affect the assistance this agency will provide.

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.

 If you are applying in person, you may fill out the application form in private.

 If you are applying by mail, call your worker. A notice is included that has your worker’s name and

telephone number.

If you fill out and sign the voter registration application, you can:



leave it with your worker,



mail it to us in the enclosed envelope or



mail it directly to the registrar of voters in your Town Hall.

Declining to register to vote and the particular office at which you register to vote remain confidential and will

be used only for voter registration purposes.

Name

Signature

Date

For Agency Use Only

Voter Registration Form Completed:

Yes

Already Registered

Voter Registration Form given to applicant for later mailing (at applicant’s request)

Agency Staff Name

Agency Staff Signature

Date

(Tear Here and Keep)

If you believe that someone has interfered with your right to register or to decline to register to vote, your

right to privacy in deciding whether to register or in applying to register to vote, or your right to choose your

own political party or other political preference, you may file a complaint with:

State Elections Enforcement Commission, 20 Trinity Street, Hartford CT 06106,

Phone: (860) 566-7106; TDD: 1-(800) 842-9710

Medicare Savings Programs Application/redetermination (Qmb, Slmb, Almb) Page 6

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