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INDIANA AGENCY VOTER REGISTRATION APPLICATION

(VRG-6)

STATE FORM 46914 (R8/12-03)

Indiana Election Commission

Receipt or Declination of Voter Registration

KEEP THIS RECEIPT FOR YOUR RECORDS

Printed Name

Signature

Address

Date (mm/dd/yy)

County of Residence

Registration Office Address

Name of Agency Employee

If you are not registered to vote where you live now, would you like to apply to register to vote today?

Yes (The agency where you apply to register is confidential.)

No (I am registered to vote at the address where I live.)

IF YOU DO NOT CHECK ANY BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER TO VOTE AT THIS TIME. The fact that you have checked “NO” is confidential and the information will be used only for voter registration purposes. If you would like help filling out the voter registration form, we will help you. The decision whether to seek or accept help is yours. You may fill out the application form in private. Applying to register or declining to register to vote will not affect the amount of assistance that you will be provided by this agency.

Box 10: Identification Documentation This documentation is only required for individuals registering to vote in the county for the first time, and are sending the application by mail. Individuals applying to register at an agency are not required to provide identification documentation.

Box 13: Voter Identification Number In Box 13, you are required to provide your Indiana driver’s license number as issued by the Bureau of Motor Vehicles. If you do not have an Indiana driver’s license, provide the last four digits of your social security number.

Acknowledgment Notice: Your application will be forwarded to your county voter registration office. The county office will send to you a notice acknowledging receipt of your voter registration application. The notice informs you whether your registration application was approved by the county voter registration office. The notice may identify where you can vote. If you have not received an acknowledgement notice within 30 days of completing this application, you should contact your county voter registration office. TAKE THIS RECEIPT TO YOUR POLLING PLACE ON ELECTION DAY. IF THIS RECEIPT INDICATES THAT YOU APPLIED TO REGISTER AT LEAST 29 DAYS BEFORE THE ELECTION YOUR RECEIPT WILL SERVE AS PROOF THAT YOU DID APPLY AND WILL PERMIT YOU TO VOTE ON ELECTION DAY, UNLESS THE COUNTY VOTER REGISTRATION OFFICE REJECTED YOUR APPLICATION.

If you believe that someone has interfered with your right to vote, your right to privacy in deciding whether to register or in applying to vote, or your right to choose your own political party or political preference, you may file a complaint with the Co-Directors of the Indiana Election Division, 302 West Washington Street, Room E204, Indianapolis, Indiana 46204-2743; (317)232-3939. If you want, you may first try to solve the problem by filing a complaint with the county voter registration office of the county where the violation occurred.

Please Print in Blue or Black Ink

Check

New registration

Indiana county where you live:

COUNTY

Date processed

Township/Precinct

County Tracking Number

boxes that

Address change (See Box 6)

USE ONLY

apply:

Name change (See Box 14)

Gender

Last Name

First Name

Middle Name or Initial

Suffix

Female

Jr. Sr. II

III

Male

Residence Address (No Post Office Boxes)

Apt. No.

City / Town

State

Zip Code

Mailing Address, if different from Box 4, if same, print “SAME”

Apt. No.

City / Town

State

Zip Code

Previous Voter Registration Address

County

Apt. No.

City / Town

State

Zip Code

Date of Birth (mm/dd/yy)

Telephone number (If available)

E-mail (If available)

Are you including identification documentation?

(See instructions for Box 10 above.)

Yes

Are you a citizen of the United States of America?

Will you be 18 years of age on or before election day?

Voter Identification Number

Yes

If this is an application for a name change, what was

Last Name

First Name

Middle Name or Initial

Suffix

your name before you changed it? If you have not

Jr. Sr. II

III

changed your name, skip this question.

Map/Diagram: If your residence has no address, street number or name (such

I authorize my voter registration at any other address to be cancelled. I swear or affirm that:

as 100 Maple Street), please draw a map showing where your residence is



I am a citizen of the United States.

located, include roads and landmarks. Otherwise, skip this question.



I will be at least 18 years of age at the next general or municipal election.



I will have lived in my precinct for at least 30 days before the next election.



I am not currently in prison after being convicted of a crime.



All the above information and all other statements on this form are true.



I understand that if I sign this statement knowing that it is not true I am committing perjury

and can be fined up to $10,000, jailed for up to three years or both.

Signature of Applicant

Date

If applicant is unable to fill out the application due to disability, the person who helped the applicant with this

application lists their name, address and telephone number in the box below. (Telephone number is optional.)

Name

Address

City/Town

Telephone Number (optional)

46914

Question	Answer
Form Name	State Form 46914
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	affirm, Suffix, Washington, E-mail

State Form 46914 – Fill Out and Use This PDF

State Form 46914 PDF Details

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