State of Utah Voter Registration Form

Yes No

Are you a citizen of the United States? If you answered “No”, do not complete this form

Yes No

Will you be at least 18 years old on or before election day?

Yes No

If you checked "no" to the above question, are you 16 or 17 years old and preregistering to vote?

If you answered "No" to both of the prior two questions, do not complete this form.

You must be a United States citizen to vote. If you fail to provide proof of United States citizenship, you will only be permitted to vote for federal offices. Information on how to provide proof of citizenship is included on the back of this form.

Last Name

First Name

Middle Name

Name at Birth (if different from above)

Suffix (Jr., Sr., II, III, IV)

Residential Address (no P.O. Boxes)

Unit or Apt. Number

City or Town

Utah

State

Zip Code

County in Utah

Same as above

Mailing Address or P.O. Box

Unit or Apt. Number

City or Town

State

Zip Code

Date of Birth:

–

YYYY

I have a valid Utah Driver's License or valid Utah ID card. Write that number here:

I do not have a valid Utah Driver's License or valid Utah ID card.
Write the last four digits of your Social Security Number here:

I do not have a valid UT Driver's License, valid UT ID card, or a Social Security Number.

Tribal Identification Number or Alien Registration Number (optional):

Place of Birth (state or country)

Place of Naturalization (if applicable)

Date of Naturalization (if applicable)

I would like to be affiliated with the following political party:

Constitution Party Democratic Party Forward Party Green Party Independent American Party Libertarian Party Peoples’ Freedom Party Republican Party Other: (specify) Unaffiliated (no party preference)

()

Phone number with area code (optional for official use - only)

Email Address (optional for official use - only)

I am a voter with a disability

Do you consent to receive communications about the status of your ballot and other official communications, by text, at the phone number you provided above? Yes No

I would like to be a poll worker

Indicate below how you want to vote in upcoming elections:

Mail a ballot to me. I intend to vote by mail. Do not mail a ballot to me. I will vote in person.

I am a voter residing outside of the U.S. I am an active military voter or a spouse/dependent of one If you checked either of the above boxes, please mark if you would like to receive your ballot at the email provided above

I have previously registered to vote

Previous Residential Address

Unit or Apt. Number

I have never registered to vote (skip this section)

City or Town

State

Zip Code

Voter registration records contain some information that is available to the public, such as your name, address, and age range. Your date of birth, driver license number, state identification card number, and social security number are available only to an authorized government entity. Your email address and phone number are also only available to anauthorized government entity.

REQUEST FOR ADDITIONAL PRIVACY PROTECTION

In addition to the protections provided above, you may request that your voter registration record be withheld from public disclosure if you are, or reside with: an individual who is a victim of, or is threatened with, domestic violence or dating violence; a law enforcement officer; a member of the armed forces; a public figure; or an individual who is protected by a court order. To make this request for additional privacy protection, you must prove that you qualify by submitting an at-risk designation request form, and any required proof, to your county clerk. You may obtain the form, and information on the proof required, from your county clerk or at vote.utah.gov.

Read and Sign below

Voter Declaration: I do swear (or affirm), subject to penalty of law for false statements, that the information contained in this form is true and that I am a citizen of the United States and a resident of the State of Utah, residing at the above address. Unless I have indicated above that I am preregistering to vote in a later election, I will be at least 18 years of age and will have resided in Utah for 30 days immediately before the election. I am not a convicted felon currently incarcerated for commission of a felony.
Citizenship Affidavit: I hereby swear and affirm, under penalties for voting fraud set forth below in Utah Code Section 20A-2-401, that I am a citizen and that to the best of my knowledge and belief the information above is true and correct.

Signature

Today’s Date

OFFICE USE ONLY

Type of ID

Voting Precinct

Voting ID #

Type: Mail