Illinois Voter Registration Application Form
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1
2ILLINOIS VOTER REGISTRATION APPLICATION
Suggested September 2015
TO COMPLETE THIS FORM:
FOR ILLINOIS RESIDENTS ONLY
SBE R-19
Box 1-If you do not have a middle name, leave blank.
TO VOTE YOU MUST:
Box 3-If mailing address is same as Box 2, write “same”.
Be a United States citizen
Box 4-If you have never registered before, leave blank. If you
Be at least 18 years old (some 17 year olds may vote in the
do not remember your former address; provide as much
General Primary)
information as possible.
Live in your election precinct at least 30 days
Box 5-If you have not changed your name, leave blank.
Not be convicted and in jail
Box 9-If you have an Illinois Driver’s License or Secretary of State
Not claim the right to vote anywhere else
ID, check the first box and fill in the number. If you do not have a
TO VOTE IN THE NEXT ELECTION:
Driver’s License or SOS ID, check the second box and fill in the
last four digits of your Social Security Number. If you do not have
Mail or deliver this application to your County Clerk or Board
a SSN, check the third box and send a copy of the appropriate
of Election Commissioners no later than 28 days before the
document (as described in the “Important Information” section)
next election.
(click here for County Clerk/Election Board
along with this form.
listings)
or go to
10-Read, date and personally sign your name or make your
IMPORTANT INFORMATION:
mark in the box.
If you do not have a driver’s license, State Identification Card or
social security number, and this form is submitted by mail, and
IF YOU HAVE NO STREET ADDRESS,
you have never registered to vote in the jurisdiction you are now
below describe your home: list the name of subdivision; cross
registering in, then you must send, with this application, either (i)
streets; roads; landmarks; mileage and/or neighbors’ names.
a copy of a current and valid photo identification, or (ii) a copy of a
current utility bill, bank statement, government check, paycheck,
N
or other government document that shows the name and address
of the voter. If you do not provide the information required above,
then you will be required to provide election officials with either (i)
W
E
or (ii) described above the first time you vote in person or prior to
voting by mail.
If you change your name you must re-register.
If you register at a public service agency, any information
regarding the agency that assisted you will remain confidential as
S
will any decision not to register.
If you do not receive a Notice within 2 weeks of mailing or
If you have questions about completing this form, please call
delivering this application, call your County Clerk or Board of
the State Board of Elections at (217)782-4141 or (312)814-6440
Election Commissioners.
(or webmaster@elections.il.gov).
TYPE OR PRINT CLEARLY IN BLACK OR BLUE INK
Are you a citizen of the United States of America?
(check one) yes
no
Office Use
Will you be 18 years of age on or before the next election day OR are you currently 17 and
will be 18 by the day of the next General Election?
(check one) yes
no
If you checked “no” in response to either of these questions, then do not complete this form.
You can use this form to: (Check One)
apply to register to vote in Illinois
change your address
change your name
1.
Last Name
First Name
Middle Name or Initial
Suffix (Circle One)
Jr. Sr. II III IV
2.
Address where you live (House No., Street Name, Apt. No.)
City/Village/Town
Zip Code
County
Township
3.
Mailing address (P.O. Box)
City/Village/Town, State
Zip Code
Email (optional)
4.
Former Registration Address: (include City and State and Zip Code)
Former County
5. Former Name: (if changed)
6.
Date of Birth: MM/DD/YY
8.
Home telephone number
9. ID number – check the applicable box and provide the appropriate number
including area code (optional)
IL Driver’s License or, if none, Sec. of State ID or
Last 4 digits of Social Security Number
7.
Sex (circle one)
(
)
-
I have none of the above-listed identification numbers.
M
F
______________________________________________________________
10. Voter Affidavit – Read all statements and sign within the box to the right.
This is my signature or mark in the space below.
I swear or affirm that
I am a citizen of the United States;
I will be at least 18 years old on or before the next election (or the
next General Election);
I will have lived in the State of Illinois and in my election precinct at least
30 days as of the date of the next election;
The information I have provided is true to the best of my knowledge under
penalty of perjury. If I have provided false information, then I may be fined,
imprisoned, or if I am not a U.S. citizen, deported from or refused entry into
the United States.
Today’s Date: __________/__________/________
11. If you cannot sign your name, ask the person who helped you fill in this form to print their name, address and telephone number.
Name of person assisting.
Full Address
Telephone No.
__________________________________________________________________________________________________________________________________
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