Mail In Voter Registration Form - State Of Utah printable pdf download

State of Utah Mail-in Voter Registration Form

Voter Instructions

You may use this form to:

● register to vote in Utah

● change your name or address on your voter registration record

● register with a party or change your party affiliation

To register to vote in Utah, you must:

● be a citizen of the United States

● have resided in Utah at least 30 days immediately before the next election

● be at least 18 years old on or before the next election

● first time voters must include a copy of a valid form of photo identification or proof of residence (or present it at the polls).

Mail-in registration instructions

● Complete all required information

● If you have registered to vote with a different name or address, complete the change of information section

● A driver license or state identification number is required. If you do not have a driver license or a state identification

card, please write “None” in the space designated for driver license or state identification and fill in the last 4 digits

of your social security number

● Read the voter declaration and citizenship affidavit and sign and date below

● Mail the form to your county clerk's office (addresses are on the back of this form).

Deadline for submitting this form

This form must be postmarked at least 30 days before an election to be eligible to vote in that election.

For more information

If you need more information, contact your county clerk at the number listed on the back of this form, or call the Lt. Governor's

Office at (801) 538-1041 or 1-800-995-VOTE.

Use pen – Please print clearly

NOTICE: In order to be allowed to vote in a voting precinct for the first time or to vote during the early voting period before the date of the election you must present

valid voter identification to the election judge before voting as follows: a valid form of photo identification that shows your name, photograph, and current address; or

two different forms of identification that show your name and current address.

Are you a citizen of the United States of America?

Yes

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

Yes

Qualifications: If you check no in response to either of these questions do not complete this form.

______________________________________________

________________________________________________________________________________________________________

Date of Birth (required, month/day/year)

Name (required) Last

First

Middle

_______________________________________________

________________________________________________________________________________________________________

Place of Birth (required, state or country)

Home Address (required, principal place of residence)

City

State

Zip Code

_______________ ______________________________

________________________________________________________________________________________________________

Last 4 Digits of

Name at Birth (if different)

Mailing Address (required if different from home address)

City

State

Zip Code

Social Security #

________________________________________________________________________________________________________

_______________________________________________

County of Residence (required)

Phone Number (optional)

Driver License or

State Issued

State Identification #

Political Party: (optional)

Unaffiliated (no party preference)

American

Constitution

Democrat

Green

Independent American

Libertarian

Natural Law

Socialist Workers

Reform

Populist

Republican

_______________________________________________

Place of Naturalization (if applicable)

Date

Personal Choice

Desert Greens

Other (please specify) _________________________________

If previously registered and/or changing personal information, also fill out this section.

I am a person with a disability (optional)

Yes

____________________________________________________________________________________________________________________________________________________________________________

Name on Previous Registration

Address on Previous Registration

City

County/Precinct (if known)

State

Zip Code

Read and sign below

Voter Declaration:

I do swear (or affirm), subject to penalty of law for false statements, that the information contained in this form is true and that I am a citizen of the

United States and a resident of the State of Utah, residing at the above address. I will be at least 18 years old on or before the next election and I will have resided in Utah

for 30 days immediately before the next election. I am not a convicted felon currently incarcerated for commission of a felony.

Citizenship Affidavit:

I hereby swear and affirm, under penalties for voting fraud set forth below in Utah Code Section 20A-2-401, that I am a citizen and that to the best of my

knowledge and belief the information above is true and correct.

Office use only:

___________________________________________________________________

Type of ID _________________________________________

Signature

Voting precinct ____________ Voting ID # _______________

Date (month/day/year)

(The above signature applies to the Voter Declaration and the Citizenship Affidavit)

MIVR05 04/2005

In accordance with Section 20A-2-401, the penalty for willfully causing, procuring, or allowing yourself to be registered to

vote if you know you are not entitled to register to vote is up to one year in jail and a fine of up to $2,500.