S
I
O
V
R
F
TATE OF
OWA
FFICIAL
OTER
EGISTRATION
ORM
Revised 4/7/2016
In Iowa, you are not qualified to vote if you have been convicted of a felony and have not received a
restoration of voting rights. You may apply to the Governor to restore your voting rights.
1.
Are you a citizen of the United States?
Yes
No
Qualifications
2.
Will you be 18 years of age on or before Election Day?
Yes
No
If you answered “No” to either of these questions, do not complete this form.
ID Number
IA driver’s license #:
Provide your Iowa
driver’s license, non‐
IA non‐operator ID #:
operator ID number,
or the last 4 digits of
Last 4 digits of Social Security number: XXX – XX –
your Social Security
number if you have
I do not have an IA driver’s license, non‐operator ID, or Social Security number.
one.
Additional
Date of Birth
/
/
(month, day, year)
Information
Sex
Male
Female
Date of birth and
sex are required.
Phone and/or Email
(optional)
Last
Your Name
First
Middle
Suffix
Street Address
Address
(include apt., lot, etc.)
Where You
City
Zip
County
Live
If homeless or you do not have an established residence, describe where you reside:
Where You
Address/P.O. Box
Receive Mail
City
State
Zip
(if different)
Previous
Your name was
Voter
Your address was
Registration
Information
Your city and state were
Your zip was
Political
Political Parties:
No Party
Democratic
Republican
Affiliation
Non‐Party Political Organizations:
Green
Libertarian
(check only one)
WARNING
Registrant Affidavit
If you sign this
I swear or affirm under penalty of perjury that:
form and you
I am the person named above.
know the
I am a citizen of the United States.
information is
I have not been convicted of a felony (or I have received a restoration of rights).
not true, you
I am at least 17 ½ years old.
may be
I live at the address listed above.
convicted of
I am not currently judged by a court to be “incompetent to vote.”
perjury and
I do not claim the right to vote anywhere else.
fined up to
$7,500 and/or
jailed for up to
5 years.
Signature
Date