City of Brockton
IMPORTANT LEGAL DOCUMENT
2012 Census ANNUAL STREET LISTING
General Laws of Massachusetts mandate an annual street listing of residents as of January 1 of each year.
Please update and correct the information provided
by
adding, deleting, or making changes below the printed
information. Please sign and return the form
in
the enclosed envelope within ten (10) days, even if no
changes are necessary. For assistance, call the Elections Commission at 508-580-7117. Office hours: Mon -
Fri 8:30AM - 4:30PM.
DETAILED INSTRUCTIONS ARE LOCATED
ON
THE BACK OF THIS FORM. PLEASE PRINT.
~
If this address
is
incorrect, make corrections below:
WARNING: FAILURE
TO
RESPOND TO THIS MAILING SHALL RESULT
IN
REMOVAL FROM THE ACTIVE VOTING LIST
AND MAY RESULT
IN
REMOVAL FROM THE VOTER REGISTRATION ROLLS. (MGL Ch. 51,
Sec.
4[c])
If there
is
no party information next
to
your name
in
column
H.
you are not a registered voter. You MAY NOT change party affiliation on this census form.
Phone
#:
Unlisted: Ward: Precinct:
A
B C
D
E
F
G
H I J K
L
"*'
W
Z
::J
1
NAME
LAST - FIRST - MIDDLE
0
~
.-J
<i:
:2
DATE OF BIRTH
MM/DDNYYY
OCCUPATION
0
W
o(f)
w<t:
>w
0
0
:2~
:20
NATIONALITY
(IF NOT U.S. CITIZEN)
>-
fo-
a:
«
0..
...J
«
II
~
:::;
0
0..
~
W
ll..
<t:
en
0
::J
co
:;)
a..
a:
~
0
>
W
>
~
II
«
.!
(f)
0
0
0
ll..
0
0
z
DON'T FORGET TO
SIGNATURE OF RESPONDENT Date
RENEW YOUR DOG LICENSE
Signed under
the
Penalties of Perjury
as
prescribed by M.G.L. Chap.
56.
Sec. 4
STARTING APRIL
1,
2012
REFER TO THE BACK OF THE FORM FOR DETAILED INSTRUCTIONS
AND ADD I T ION A
LIN
FOR MAT ION
Copyright
2007-2012
M.,k
Allman
&
Associates,
Inc
.
All
Rights
Reserved
E-mail
Print
CITY OF BROCKTON - SPECIAL INSTRUCTIONS: RETURN WITHIN TEN (10) DAYS
COMPLIANCE with this State requirement provides proof of residence, protection of voting rights, veteran's bonus, housing for the
elderly and related benefits
as
well as providing information for your community. This
form
DOES NOT register you as a voter,
or
allow
you
to
change
your
political party. To register
or
change party, please obtain a mail-in registration
form
by
calling 800-462-8683
or
contact the Elections Commission. You
must
be a registered
voter
at least
twenty
(20) days
prior
to
State Primaries and Elections.
GENERAL INSTRUCTIONS: PLEASE PRINT
Please verify and/or complete all information listed on this form, then sign and date it. Make corrections as
necessary.
RESIDENT ADDRESS - If your resident address
is
incorrect, make the change
in
the space to the right of the
incorrect address.
PHONE NUMBER - Please print and/or verify your phone number
in
the indicated space.
If
unlisted, put
an
"X" in the box next to the word "Unlisted".
DELETIONS - Put a line through the name of any resident no longer residing at this address and list his/her
new address. Make all changes on the SHADED line below the printed line.
A - LINE NUMBER
B - NAMES OF
ALL
FAMILY / HOUSEHOLD MEMBERS
AT
THIS ADDRESS - Includes any member of the
family
in
Military Service, away at school or confined to a rest home. If a NEW member has been added to
the family or household, enter the name and information
in
the space provided on the form.
C -
MAIL
TO - This
is
the designated individual to whom this form has been sent. If you wish to change your
designated mail to contact, please place a "Y" next to the name of the selected individual. ONLY ONE "HEAD
OF HOUSEHOLD" may be designated
in
order to have the entire family listed together.
D - DATE OF BIRTH - "MM
=Month,
DD
=Day, YYYY =Year." If your date of birth is blank or incorrect,
please make appropriate changes.
E - OCCUPATION - Enter occupation, not place of employment.
F - MOVED/DECEASED - If this person has moved or is deceased, please indicate with
an
"M" or "D".
G - NATIONALITY -
If
you are NOT a U.S. Citizen, please indicate your nationality.
H - POLITICAL PARTY - "R" for REPUBLICAN, "D" FOR DEMOCRAT,
"J" for GREEN-RAINBOW PARTY
and "U" for UNENROLLED. All other letters represent political party designations. This reflects the
information on file and can only
be
updated by completing the necessary voter registration or party enrollment
change form.
I - PUBLIC SAFETY - Check this box if you are a member of a public safety agency and WORK AND LIVE
IN
THIS COMMUNITY.
J - VOTER STATUS - Indicates whether a person is an active or inactive voter. Returning this form will
reactivate voter status unless the voter indicates that he / she has moved and signs the form.
K - NO. OF DOGS - Number of dogs licensed to this individual.
L - VETERAN - Write a "Y" if you are a veteran of the U.S. Armed Forces.
IF YOU HAVE
ANY
QUESTIONS, PLEASE
CALL
THE ELECTIONS COMMISSION
AT
508·580·7117
To return
this
form
Refold,
insert
into
the provided return envelope and mail
Thank
you
for
your
cooperation
Copyright 2007-2012 Mark Altman & Associa!es, Inc All Rights Reserved.
MAIL FORM TO: ELECTIONS COMMISSION
45 SCHOOL ST.
BROCKTON, MA 02301
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome