Bhsf Form 1-Hpe - Assessment Tool For Hospital Presumptive Eligibility (Hpe) Only Page 2
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4STATE OF LOUISIANA
VOTER REGISTRATION AGENCIES
DECLARATION FORM
If you are not registered to vote where you live now, would you like to apply
to register to vote here today? (Check one)
[ ] I want to register to vote.
[ ] I do not want to register to vote.
IF YOU DO NOT CHECK EITHER BOX, YOU WILL BE CONSIDERED TO HAVE
DECIDED NOT TO REGISTER TO VOTE AT THIS TIME.
Applying to register or declining to register to vote will not affect the amount of assistance that you will be
provided by this agency. Voter eligibility requirements are found on the voter registration application form.
Note:
If you do register to vote, the location where your application was submitted will remain
confidential. If you decline to register to vote, this fact will remain confidential. Applying to register or
declining to register to vote will be used only for voter registration purposes.
If you would like help in filling out the voter registration application form, we will help you. The
decision whether to seek or accept help is yours. You may fill out the application in private.
(Check one)
[ ] Yes, I would like help.
[ ] No, I do not want help.
For assistance in completing the voter registration application form outside our office, contact Louisiana
Department of Health and Hospitals at 1-888-342-6207.
If completed outside our office, this declaration form and your completed voter registration application
form (if you filled one out) should be returned to P.O. Box 91278 Baton Rouge, LA 70821-9278.
Signature or Mark
Name Typed or Printed
Date
Signatures of Two Witnesses If Signed With Mark:
1) ____________________________________
2) _______________________________________
COMPLAINTS
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 the Louisiana Secretary
of State, Commissioner of Elections, P.O. Box 94125, Baton Rouge, LA 70804-9125 or by calling
(225)922-0900 or 1-800-883-2805.
Comments/Remarks (for official use only):
NVRADF
Rev. 3/13
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