Fillable DS-DE 39 Florida Voter Registration Application (Florida Division of Corporations)

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DS-DE 39 Florida Voter Registration Application (Florida Division of Corporations)

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Florida Voter Registration Application-Part 1 – Instructions
To Register in Florida, you must be:
a U.S. citizen,
a Florida resident,
at least 18 years old (you may pre-register at 16 or 17, but
cannot vote until you are 18).
If you have been convicted of a felony, or if a court has found
you to be mentally incapacitated as to your right to vote, you
cannot register until your right to vote is restored.
If you do not meet any ONE of these requirements, you are
not eligible to register.
Questions?
Contact the Supervisor of Elections in your county:
dos.elections.myflorida.com/supervisors/
Visit the Florida Division of Elections’ website at:
dos.myflorida.com/elections/
Where to Register: You can register to vote by completing this application and delivering it in person or by mail to
any supervisor of elections’ office, office that issues driver’s licenses, or voter registration agency (public assistance
office, center for independent living, office serving persons with disabilities, public library, or armed forces
recruitment office) or the Division of Elections. Mailing addresses are on page 2 of this form.
Deadline to Register: The deadline to register to vote is 29 days before any election. You can update your
registration record at any time, but for a Primary Election, party changes must be completed 29 days before that
election. You will be contacted if your new application is incomplete, denied or a duplicate of an existing registration.
Your Voter Information Card will be mailed to you once you are registered.
Identification (ID) Requirements: New applicants must provide a current and valid Florida driver’s license number
(FL DL#) or Florida identification card number (FL ID#). If you do not have a FL DL# or FL ID#, then you must
provide the last four digits of your Social Security number (SSN). If you do not have any of these numbers, check
“None.” If you leave the field and box blank, your new registration may be denied. See section 97.053(6), Fla.Stat.
utility bill, bank statement,
government check, paycheck, or other government document).
U.S. Passport, debit or credit card, military
ID, student ID, retirement center ID, neighborhood association ID, or public assistance ID); or 2) A copy of an ID
that shows your name and current residence address (acceptable documents
Special ID requirements: If you are registering by mail, have never voted in Florida, and have never been issued
one of the ID numbers above, include one of the following with your application, or at a later time before you vote:
1) A copy of an ID that shows your name and photo (acceptable IDs--
--
The special ID is not required if you are 65 or older, have a temporary or permanent physical disability, are a member
of the active uniformed services or merchant marine who is absent from the county for active duty, or a spouse or
dependent thereof, or are currently living outside the U.S. but otherwise eligible to vote in Florida.
Political Party Affiliation: Florida is a closed primary election state. In primary elections, registered voters can
only vote for their registered party’s candidates in a partisan race on the ballot. In a primary election, all registered
voters, regardless of party affiliation, can vote on any issue, nonpartisan race, and race where a candidate faces no
opposition in the General Election. If you do not indicate your party affiliation, you will be registered with no party
affiliation. For a list of political parties, visit the Division of Elections’ website at: dos.myflorida.com/elections/
Race/Ethnicity: It is optional to list your race or ethnicity.
Boxes: Please check boxes () where applicable.
CRIMINAL OFFENSE: It is a 3rd degree felony to submit false
information. Maximum penalties are $5,000 and/or 5 years in
prison.
PUBLIC RECORD: Once filed, all information including your
phone number and email address as provided become public
record except for the following which can only be used for voter
registration purposes: your FL DL#, FL ID#, SSN, where you
registered to vote, and whether you declined to register or to
update your voter registration record at a voter registration
agency. Your signature can be viewed but not copied. (Section
97.0585, Fla. Stat.)
Numbered rows 1 through 7 and 12 must be completed for a new registration.
Florida Voter Registration Application
Part 2 – Form (DS-DE #39, R1S-2.040, F.A.C.)(eff. 7/2019)
Form available online at/Formulario disponible en línea en:
registertovoteflorida.gov
This is: New Registration Record Update/Change (e.g., Address, Party Affiliation, Name, Signature) Request to Replace Voter Information Card
1
Are you a citizen of the United States of America? YES NO
2
I affirm I have never been convicted of a felony.
If I have been convicted of a felony, I affirm my voting rights have been restored by
the Board of Executive Clemency.
pursuant to s. 4 , Art. VI of the State Constitution upon the completion of all terms of
my sentence, including parole or probation.
If I have been convicted of a felony, I affirm my voting rights have been restored
3
mentally incapacitated with respect I affirm that I have not been adjudicated to voting or, if I have, my right to vote has been restored.
4
Date of Birth (MM-DD-YYYY)
-
-
5
Florida Driver License (FL DL) or Florida identification (FL ID) Card Number
If no FL
DL or FL
ID, then
provide
Last 4 digits of Social
Security Number
I have
NONE of
these
numbers.
-
-
-
-
6
Last Name
First Name
Middle Name
Name Suffix
(Jr., Sr., I, II, etc.):
7
Address Where You Live (legal residence-no P.O. Box)
Apt/Lot/Unit
City
County
Zip Code
8
Mailing Address (if different from above address)
Apt/Lot/Unit
City
State or Country
Zip Code
9
Address Where You Were Last Registered to Vote
Apt/Lot/Unit
City
State
Zip Code
10
Former Name (if name is changed)
Gender
M F
State or Country of Birth
Telephone No. (optional)
( )
11
Email me SAMPLE BALLOTS if option is available in my county.
(See Public Record Notice above) My email address is:
Party Affiliation
(Check only one. If left blank, you will
be registered without party affiliation)
Florida Democratic Party
Republican Party of Florida
No party affiliation
Minor party (print party name):
______________________
Race/Ethnicity (Check only one)
American Indian/Alaskan Native
Asian/Pacific Islander
Black, not of Hispanic Origin
Hispanic
White, not of Hispanic Origin
Multi-racial
Other:________________
(Check only one if applicable)
I am an active duty Uniformed Services or Merchant
Marine member
I am a spouse or a dependent of an active duty uniformed
services or merchant marine member
I am a U.S. citizen residing outside the U.S.
I will
need
assistance
with voting.
I am
interested in
becoming a
poll worker.
12
Oath: I do solemnly swear (or affirm) that I will protect
and defend the Constitution of the United States and
the Constitution of the State of Florida, that I am
qualified to register as an elector under the Constitution
and laws of the State of Florida, and that all information
provided in this application is true.
SIGN/
MARK
HERE
Date
-
✔
Addressyourenvelopeto
yourCountySupervisorof
Elections.(Rev07/2019)
Flagle
r
-Supervisor of Elections
PO Box 901
Bunnell, FL 32110
386-313-4170
Lake-Supervisor of Elections
PO Box 457
Tavares, FL 32778
352-343-9734
Pasco-Supervisor of Elections
PO Box 300
Dade City, FL 33526
800-851-8754
Alachua-Supervisor of Elections
515 North Main Street, Suite 300
Gainesville, FL 32601-3348
352-374-5252
Franklin-Supervisor of Elections
47 Ave F
Apalachicola, FL 32320
850-653-9520
Lee-Supervisor of Elections
2480 Thompson St
Fort Myers, FL 33901
239-533-8683
Pinellas-Supervisor of Elections
13001 Starkey Road
Largo, FL 33773-1416
727-464-8683
Bake
r
-Supervisor of Elections
PO Box 505
Macclenny, FL 32063
904-259-6339
Gadsden-Supervisor of Elections
PO Box 186
Quincy, FL 32353
850-627-9910
Leon-Supervisor of Elections
PO Box 7357
Tallahassee, FL 32301
850-606-8683
Polk-Supervisor of Elections
PO Box 1460
Bartow, FL 33831
863-534-5888
Bay-Supervisor of Elections
830 W. 11th Street
Panama City, FL 32401
850-784-6100
Gilchrist-Supervisor of Elections
112 S. Main Street, Rm 128
Trenton, FL 32693
352-463-3194
Levy-Supervisor of Elections
421 South Court Street
Bronson, FL 32621
352-486-5163
Putnam-Supervisor of Elections
2509 Crill Ave, Ste. 900
Palatka, FL 32177
386-329-0224
Bradford-Supervisor of Elections
PO Box 58
Starke, FL 32091
904-966-6266
Glades-Supervisor of Elections
PO Box 668
Moore Haven, FL 33471
863-946-6005
Liberty-Supervisor of Elections
PO Box 597
Bristol, FL 32321
850-643-5226
Santa Rosa-Supervisor of Elections
6495 Caroline Street, Suite F
Milton, FL 32570
850-983-1900
Brevard-Supervisor of Elections
2725 Judge Fran Jamieson Way
Melbourne, FL 32940
321-633-2124
Gul
f
-Supervisor of Elections
401 Long Avenue
Port St. Joe, FL 32456
850-229-6117
Madison-Supervisor of Elections
239 SW Pinckney St.
Madison, FL 32340
850-973-6507
Sarasota-Supervisor of Elections
PO Box 4194
Sarasota, FL 34230-4194
941-861-8600
Broward-Supervisor of Elections
PO Box 029001
Ft. Lauderdale, FL 33302
954-357-7050
Hamilton-Supervisor of Elections
1153 US Hwy. 41 NW, Ste. 1
Jasper, FL 32052
386-792-1426
Manatee-Supervisor of Elections
PO Box 1000
Bradenton, FL 34206-1000
941-741-3823
Seminole-Supervisor of Elections
PO Box 1479
Sanford, FL 32772-1479
407-585-8683
Calhoun-Supervisor of Elections
20859 Central Ave. East, Rm 117
Blountstown, FL 32424
850-674-8568
Hardee-Supervisor of Elections
311 North 6th Ave.
Wauchula, FL 33873
863-773-6061
Marion-Supervisor of Elections
PO Box 289
Ocala, FL 34478-0289
352-620-3290
St. Johns-Supervisor of Elections
4455 Avenue A, Suite 101
St. Augustine, FL 32095
904-823-2238
Charlotte-Supervisor of Elections
226 Taylor St., Unit 120
Punta Gorda, FL 33950
941-833-5400
Hendry-Supervisor of Elections
PO Box 174
LaBelle, FL 33975-0174
863-675-5230
Martin-Supervisor of Elections
PO Box 1257
Stuart, FL 34991
772-288-5637
St. Lucie-Supervisor of Elections
4132 Okeechobee Road
Fort Pierce, FL 34947
772-462-1500
Citrus-Supervisor of Elections
120 North Apopka Ave.
Inverness, FL 34450
352-341-6740
Hernando-Supervisor of Elections
20 N. Main St., Rm 165
Brooksville, FL 34601
352-754-4125
Miami-Dade-Supervisor of Elections
2700 NW 87th Ave
Miami, FL 33172
305-499-8363
Sumte
r
-Supervisor of Elections
7375 Powell Road, Suite 125
Wildwood, FL 34785
352-569-1540
Clay-Supervisor of Elections
PO Box 337
Green Cove, FL 32043
904-269-6350
Highlands-Supervisor of Elections
PO Box 3448
Sebring, FL 33871-3448
863-402-6655
Monroe-Supervisor of Elections
530 Whitehead St #101
Key West, FL 33040-6577
305-292-3416
Suwanee-Supervisor of Elections
220 Pine Ave. S.W.
Live Oak, FL 32064
386-362-2616
Collie
r
-Supervisor of Elections
3750 Enterprise Avenue
Naples, FL 34104
239-252-8683
Hillsborough-Supervisor of
Elections
2514 North Falkenburg Rd.
Tampa, FL 33619
813-744-5900
Nassau-Supervisor of Elections
96135 Nassau Place, Suite 3
Yulee, Florida 32097
904-491-7500
Taylo
r
-Supervisor of Elections
PO Box 1060
Perry, FL 32348
850-838-3515
Columbia-Supervisor of Elections
971 West Duval St., Suite 102
Lake City, FL 32055
386-758-1026
Holmes-Supervisor of Elections
201 N. Oklahoma St., Ste. 102
Bonifay, FL 32425
850-547-1107
Okaloosa-Supervisor of Elections
302 North Wilson St., Suite 102
Crestview, FL 32536
850-689-5600
Union-Supervisor of Elections
175 West Main St.
Lake Butler, FL 32054
386-496-2236
Desoto-Supervisor of Elections
PO Box 89
Arcadia, FL 34265
863-993-4871
Indian Rive
r
-Supervisor of Elections
4375 43rd Avenue
Vero Beach, FL 32967
772-226-3440
Okeechobee
-Supervisor of Elections
304 NW 2nd Street, Rm 144
Okeechobee, FL 34972
863-763-4014
V
olusia-Supervisor of Elections
125 W. New York Ave.
DeLand, FL 32720
386-736-5930
Dixie-Supervisor of Elections
PO Box 2057
Cross City, FL 32628
352-498-1216
Jackson-Supervisor of Elections
PO Box 6046
Marianna, FL 32447
850-482-9652
Orange-Supervisor of Elections
PO Box 562001
Orlando, FL 32856-2001
407-836-2070
Wakulla-Supervisor of Elections
PO Box 305
Crawfordville, FL 32326
850-926-7575
Duval-Supervisor of Elections
105 East Monroe St.
Jacksonville, FL 32202
904-630-1414
Jefferson-Supervisor of Elections
435 W. Walnut St.
Monticello, FL 32344
850-997-3348
Osceola-Supervisor of Elections
2509 E. Irlo Bronson Memorial Hwy
Kissimmee, FL 34744
407-742-6000
Walton-Supervisor of Elections
571 US Hwy. 90 East
DeFuniak Springs, Florida 32433
850-892-8112
Escambia-Supervisor of Elections
PO Box 12601
Pensacola, FL 32591
850-595-3900
Lafayette-Supervisor of Elections
PO Box 76
Mayo, FL 32066
386-294-1261
Palm Beach-Supervisor of Elections
PO Box 22309
West Palm Beach, FL 33416-2309
561-656-6200
Washington-Supervisor of Elections
1331 South Blvd., Suite 900
Chipley, FL 32428
850-638-6230
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DS-DE 39 Florida Voter Registration Application (Florida Division of Corporations)

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Completed 30 July 2020

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