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DRAFT - DO NOT USE THIS FORM
Iowa Mail-In Voter Registration Application
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Voter Qualifications:
To register to vote in Iowa, you must:
- Be a citizen of the United States
- Be a resident of Iowa
- Be at least 17 1/2 years old (you must be 18 to vote.)
- Not have been convicted of a felony (or have had your rights
restored.)
- Not currently be judged "mentally incompetent" by a court
- Give up your right to vote in any other place.
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Deadlines for registering to vote are 10 days before a primary or
general election; 11 days before any other election. You may register
after the deadline, but your registration will not be effective until
after that election. Normally, an application must be received by the
deadline in order to be valid for the election. However, if your
registration is postmarked at least 15 days before the election, it will
be accepted for that election even if it is received after the deadline.
Registration is permanent. After you register, you do not have to
register again unless you move to a new address. |
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Instructions:
Use this form to:
Register to vote; or
Report a change of name,address, telephone number, or party affiliation.
2. Place in stamped envelope and mail to:
TOM SLOCKETT,
Johnson County Auditor
913 S. Dubuque St. Suite 101
Iowa City, IA 52240
3. You should receive a receipt of this application within 14 days. If
you do not, contact your county auditor. Be ready to tell when and where
you filled out the form and to whom you gave it.
Notice to people who receive this form at state agencies:
If you register to vote, the name of the office where you received this
form will be kept private. That information will be used only to keep
track of how many people registered at that office.
If you decide not to register to vote, the fact that you did not
register will be kept private. That information will be used only for
voter registration purposes. |
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Full Name - Last First
Middle Suffix (Jr., Sr., III, etc.)
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Date of Birth
/ /
Mo/Day/Year |
Sex
¨ Female
¨ Male |
Soc. Sec. Num. (See Privacy Act Notice at the bottom of
this form.)
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Address where
Number
Street
Apt, Lot, etc.
City,
State,
Zip
You live:
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Address where
Number
Street
Apt, Lot, etc.
City,
State,
Zip
You get your mail (if
you use a post office
box or mail drop)
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Party Affiliation
¨ Democratic
¨ Green
¨ Republican
¨ None |
Telephone number with area code
( ) |
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If you have no street address because you use a rural route address, or
because you are homeless, please list your
township _____________________________ and section number
_______________________
Or describe where you live:
________ ________ and _______ ________ of
_____________________________________
(Mi or blks) (N,S,E,W) (Mi or blks) (N,S,E,W)
(Landmark or highway junction)
If you have ever been registered to vote before, complete this section:
Your name then:
____________________________________________________________________________
Your address then:
__________________________________________________________________________
City, State, Zip Code:
_______________________________________________________________________
Name of the County:
_______________________________________________________________________ |
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Read the following and sign below:
I swear or affirm that:
- I am the person named above
- I am a United States citizen
- I live at the address listed above
- I am at least 17 1/2 years old
- I have not been convicted of a felony (or have received a
restoration of rights)
- I am not currently judged mentally incompetent by a court
- I do not claim the right to vote anywhere else.
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DRAFT - DO NOT USE THIS FORM___________
__________________
Signature
Date
WARNING: If you sign this statement and you know it is not true, you
can be convicted and fined up to $7,500 and/or jailed for up to five
years.
Privacy Act Notice: Disclosure of your social security number on this
voter registration application is voluntary. It is requested by authority
of 1994 Iowa Acts, SF 2223. Failure to provide the number will have no
effect on your right or your right to vote. If you provide your number, it
will be used to help avoid multiple registrations for a single individual.
It may also be disclosed to those who purchase lists of registered voters
and to those who view original voter registration records, which are
public records under Iowa law.
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