Bhsf Form 1-Hpe - Assessment Tool For Hospital Presumptive Eligibility (Hpe) Only Page 4

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1) register to vote

2) change your address

3) request a name change

4) change party affiliation

USE THIS FORM TO:

TO REGISTER TO VOTE AND BE ELIGIBLE TO VOTE YOU MUST: 1) be a United States citizen 2) be at least 17 years old to register but must be 18 years old to vote 3) not be under an

order of imprisonment for conviction of a felony 4) not be under a judgment of full interdiction or limited interdiction where your right to vote has been suspended 5) reside in the state and parish

in which you seek to register and vote.

INSTRUCTIONS FOR COMPLETING THIS FORM: All information except your signature should be printed clearly in ink, preferably black, or typed. Fill in all boxes that apply to you.

Box 1: Indicate whether you are a citizen of the United States of America. Indicate whether you will be 18 years of age on or before election day.

Box 2: Provide full name. Do not use initials for middle or maiden name.

Box 3: 'Residence Address' means the address where you live and are registering to vote. If you claim a homestead exemption, you must list the address of that residence. Do not use

a post office box for your 'Residence Address'. If you use a rural route and box number, draw a map in the space labeled 'Give Location.' Write in the names of the crossroads (streets)

nearest to where you live. Draw an X to show where you live. Use a dot to show any schools, churches, stores or landmarks near where you live and write the name of the landmark.

Check the box provided if mail is not delivered to your residence address by the post office. Complete 'Mailing Address' only if it is different from the 'Residence Address' or if mail is not

delivered to your residence address.

Boxes 5 & 13: You must provide your LA driver's license number or LA special identification card number, if issued. If not issued, you must provide at least the last four digits of

your social security number, if issued. The full social security number may be provided on a voluntary basis. If neither a social security number nor a LA driver's license number or LA

special identification card number has been issued, and this form is submitted by mail, and you are registering to vote for the first time, in order to avoid additional identification

requirements for first time voters, attach either a) a copy of a current and valid photo identification or b) a copy of a current utility bill, bank statement, government check, paycheck, or

other government document that shows your name and address.

Boxes 7, 11 & 12: The items 'race/ethnic origin', 'email' and 'phone' are not required but are helpful. Email is protected from disclosure by law.

Box 8: If you do not complete this item, your party affiliation will be listed as 'no party', unless you are presently registered with a party affiliation and no change is being made today. If

you are not registering with a political party, circle ‘no party’. The recognized political parties are Democrat, Green, Libertarian, Reform and Republican or you may specify any other

party affiliation.

Box 17: If you are using this form to request a change of name, you must print the name to be changed here.

Box 18: Date and sign the card with your signature or mark.

If returned by mail, place in an envelope and mail to the appropriate registrar of voters at the address found on the reverse side of this card. If you have not been issued a social security

number or Louisiana driver's license number, you must mail the required documentation with your application. Your application or envelope must be postmarked 30 days prior to the first

election in which you seek to vote based on the residence listed on this application.

NOTE: 1. If you decline to register to vote, this fact will remain confidential and will be used only for voter registration purposes. If you register to vote, the office where your application

was submitted will remain confidential and will be used only for voter registration purposes. 2. Your social security number will also remain confidential and is intended to be used for

voter registration purposes only.

QUESTIONS? Call your Parish Registrar of Voters OR call the Department of State at 1-800-883-2805 or (225) 922-0900.

COMPLETE AND CHECK ALL APPLICABLE BOXES AND CUT HERE BEFORE MAILING.

LOUISIANA VOTER REGISTRATION

OFFICIAL USE ONLY

APPLICATION

LR-1 & 1M, FORM #100

Wd / Dist _________ Pct _______ Reg Type _________

In/Out _______ REG # _____________________________



1 Are you a citizen of the United States of America?

YES

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

If you checked ‘no’ in response to either of these questions, DO NOT COMPLETE THIS FORM.

2 NAME OF APPLICANT (PLEASE PRINT NAME)

GIVE LOCATION

LAST

FIRST

FULL MIDDLE OR MAIDEN

3 RESIDENCE ADDRESS

(MUST BE ADDRESS WHERE YOU CLAIM HOMESTEAD EXEMPTION, IF ANY)

HOUSE OR APT. NO. & STREET (IF RURAL, ROUTE & BOX NO.)

CITY OR TOWN

STATE

ZIP

If NO mail delivery to residential

MAILING ADDRESS, IF DIFFERENT

(

)

address, check here:

4 DATE OF BIRTH

5 * SOCIAL SECURITY #

6 SEX

7 ** RACE / ETHNIC ORIGIN

(CIRCLE ONE)

MONTH

DAY

YEAR

WHITE

BLACK

ASIAN

HISPANIC

AMER. INDIAN

MALE

FEMALE

YES # ____________________________________

OTHER: _____________________________________________

8 PARTY AFFILIATION

9 APPLICANT’S PLACE OF BIRTH

10 MOTHER’S MAIDEN NAME

(CIRCLE ONE)

CITY OR TOWN

PARISH OR COUNTY

STATE

COUNTRY

DEM

GRN

LBT

RFM

REP

NO PARTY

OTHER

(SPECIFY) _________________________

11 **EMAIL

12 ** PHONE

13 LA DRIVER’S LICENSE / I.D. #

14 Will you require assistance at the polls?

CIRCLE ONE)

(CIRCLE

(

ONE)

HOME (

)

NO YES

IF YES, GIVE REASON :

YES # ______________________________________

DAY

(

)

15 LAST RESIDENCE ADDRESS

16 PLACE OF LAST REGISTRATION

17 FORMER REGISTERED NAME, IF APPLICABLE

ADDRESS

PARISH OR COUNTY

STATE

AFFIRMATION: I do hereby solemnly swear or affirm that I am a United States citizen, that I am at least 17 years old, that I am not currently under an order of imprisonment for

conviction of a felony, that I am not currently under a judgment of full interdiction or limited interdiction where my right to vote has been suspended, that I am a bona fide resident of this

state and parish, and that the facts given by me on this application are true to the best of my knowledge and belief. If I have provided false information, I may be subject to a fine of not

more than $2,000 ($5,000 for subsequent offense) or imprisonment for not more than 2 years (5 years for subsequent offense), or both. Any false statement may constitute perjury.

18 SIGN YOUR NAME IN BOX AT RIGHT.

DATE: ____________________________ / __________ / _________________

19 IF YOU ARE UNABLE TO SIGN YOUR NAME, TWO WITNESSES TO YOUR MARK MUST SIGN HERE.

WITNESS SIGNATURE:

* Last 4 digits of the social security number required if no LA driver's license issued; social security number is intended to be used for voter registration purposes only;

full # OPTIONAL.

** OPTIONAL

LR-1 & 1M (REV. 12/12) R.S. 18:104;

FORM #100