Voter Registration Card Statement Of Distribution
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1
2Voter Registration Card
Statement of Distribution
(Office Use Only)
I.
General Information
Name:
Date:
Name of Organization:
Street Address (No P O Box):
City:
State:
Zip:
Telephone: (
)
Fax: (
)
Number of Cards Requested:
Language:
II.
Proposed Method of Distribution (Check)
Fixed Location
Mail (Blanket)
Petition
Door-to-Door
Mail (Targeted)
Other
Briefly explain your distribution plan (where will forms be distributed, by whom will they be distributed, etc.).
III.
Declaration
I declare under penalty of perjury that I have read and understand the legal requirements on the reverse side of this form and that I will
take reasonable steps to ensure that:
1) The person or persons distributing registration cards will give a registration card to any elector requesting one; and
2) The voter registration cards issued will not be defaced or changed in any way, other than by the insertion of a mailing address and
the affixing of postage; and
3) Prior to distribution, the affidavit portion of the registration cards will not be marked, stamped, or partially or fully completed by
anyone other than an elector or by another person assisting the elector; and
4) Persons entrusted with distribution or subsequent collection of completed forms, will be fully advised of the legal requirements
outlined on the reverse side of this statement.
Signature:
Date:
(Important: See Legal Requirements on reverse side of this Statement)
(Office Use Only)
Serial Numbers:
Fax This Completed Form To: (916) 653-3214
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Parent category: Life