Individual Change Of Address
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1INDIVIDUAL CHANGE OF ADDRESS/
CATER
VOTER REGISTRATION APPLICATION
STATE OF CONNECTICUT
B-58 IND Rev. 9-2016
DEPARTMENT OF MOTOR VEHICLES
CIVLS
INSTRUCTIONS: (Please print in ink or type):
Section A: Individual Address Change
Section B: New Voter Registration Application/Change of Party Affiliation
Section C: Registration and Vessel Information
PLEASE MAIL COMPLETED FORM TO: Department of Motor Vehicles Change of Address Unit, 60 State Street, Wethersfield, CT 06161
SECTION A - INDIVIDUAL ADDRESS CHANGE
SECTION B - VOTER REGISTRATION APPLICATION
DRIVER LICENSE OR ID NUMBER
Complete Section B if:
•
You are registering to vote for the first time.
OR
BIRTH DATE
LICENSE/ID EXPIRATION DATE DAYTIME TELEPHONE NUMBER
•
You are already a registered voter and would like to change your political
party affiliation.
NAME OF APPLICANT (First, Middle, Last)
TO REGISTER TO VOTE YOU MUST BE: A United States citizen; at least 18 years
of age (by election day); and a resident of Connecticut and the city or town where
you are applying to register to vote.
RESIDENCE ADDRESS
Check here if this is a new address
(Must be included)
Are you a citizen of the United States of America?
YES
NO
ADDRESS (Number, Street and if applicable, Unit/Apartment number)
Will you be 18 years of age on or before election day?
YES
NO
If you checked "NO" in response to either of these questions, do
(City or Town, Zip Code, County)
NOT complete below this line as you cannot register to vote.
MAILING ADDRESS
Check here if this is a new mailing address
Do you wish to enroll in a political party?
If different
ADDRESS (Number, Street and if applicable, Box number)
YES
NAME OF PARTY:
DEMOCRATIC
REPUBLICAN
OTHER:
(City or Town, Zip Code)
NO
I DO NOT WISH TO ENROLL IN A PARTY AT THIS TIME AND
WILL BE REGISTERED AS UNAFFILIATED
Check here to remove current mailing address on file
Note: Declaring a party enables you to vote in the party's primary election, which is
Check here if this change of address is NOT for voter registration purposes
open only to party members. You may later choose to switch enrollment to or from a
political party.
If you are already a registered voter and you do not check this box, your
address will be changed in your voter record as follows: (1) If your new
LEAVING THIS SECTION BLANK WILL AUTOMATICALLY RESULT IN SELECTING
address is in the same city/town, your address will be updated with the
UNAFFILIATED
registrar in your city/town; or (2) if your new address is in a different
city/town, this form will be used for voter registration in your new city/town.
E-MAIL
VOTER DECLARATION:
Add e-mail address
Remove e-mail address
Change e-mail address
•
I swear or affirm under penalty of perjury that:
* I am a U.S. Citizen
By checking the box above you understand all registration renewals will be sent to you
* I live in Connecticut at the address shown above
ONLY via e-mail
* I am at least 17 years old
E-MAIL ADDRESS HERE:
* I have not been convicted of a disfranchising felony, or if so,
I am eligible to register to vote
SIGNATURE OF APPLICANT**
TODAY'S DATE
ORGAN DONOR
I consent to organ and tissue donation and wish to be in the donor registry
I no longer wish to be in the donor registry
**Voter registrations without signatures will not be processed.
The information that I have provided is true to the best of my knowledge under penalty
SIGNATURE OF APPLICANT*
TODAY'S DATE
of perjury. If I have provided false information, I may be subject to a fine or
imprisonment or both under federal or state laws.
*Forms without a signature will not be processed.
By signing this application form, you agree to allow the signature from your license
record to be used as the signature on your voter registration record.
SECTION C
VEHICLE REGISTRATION INFORMATION
VESSEL INFORMATION
CT TOWN AND STREET ADDRESS WHERE VEHICLE IN THE NORMAL COURSE OF
PLATE NUMBER
CT/NUMBER
OPERATION MOST FREQUENTLY LEAVES FROM, RETURNS TO OR REMAINS
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