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Prescribed by Secretary of State
Section 63.001(i), Texas Election Code
1/2018
REASONABLE IMPEDIMENT DECLARATION
Instructions: If a voter appears on the official list of registered voters, but does not possess an acceptable form of
photo identification under Section 63.0101 (a) of the Texas Election Code (which, for voters aged 18‐69, has expired by no
more than four years, and for voters aged 70 or over, is or is not expired, if otherwise valid) (“Acceptable Photo ID”), and
cannot reasonably obtain an Acceptable Photo ID, the following steps shall be taken by the election officer to allow the
voter to cast a regular ballot:
1. Present this form to the voter, and ask the voter to provide a copy or original of one of the following forms
of identification listed in Section 63.0101(b) of the Texas Election Code:
a.
a certified domestic (from a U.S. state or territory) birth certificate or a document confirming birth admissible
in a court of law which establishes the voter’s identity (which may include a foreign birth document);
b. a current utility bill;
c. a bank statement;
d. a government check;
e. a paycheck; or
f.
a government document that shows the voter’s name and an address (which includes the voter’s voter
registration certificate).
NOTE: The address on the identification presented is not required to match the address recorded in
the official list of registered voters.
NOTE: If on Election Day, a presented voter registration certificate indicates that the voter is appearing
at the incorrect polling place, the voter should be directed to the correct polling place.
2. Ask the voter to complete this form by entering their name, and then ask them to review the “Voter’s
Declaration of Reasonable Impediment”, indicate their impediment, and sign their name.
3. Ask the voter to return the completed form to you. Neither you nor the election judge may question the voter
concerning the reasonableness of any claimed impediment. The election judge should enter the date and
then sign on the space provided on the declaration.
4. Either you or the election judge shall fill in the voter’s Voter Unique Identification Number (“VUID”) in the appropriate
box or affix a sticker that contains that information across the box, and note on the combination form that the
declaration was used by the voter. Either you or the election judge should indicate on the “To Be Completed
By Election Official” form what type of document the voter provided by checking the appropriate box. Either
you or the election judge should fill in the Date of Election and Location fields.
5. Allow the voter to cast a regular ballot.
NOTE: This form may also be used if a voter voted provisionally and does not possess and cannot reasonably obtain an
acceptable form of photo identification, and appears at the county voter registrar’s office within six (6) calendar days after
election day to execute a reasonable impediment declaration and present one of the supporting forms of identification, in
accordance with Section 65.0541 of the Texas Election Code. In that instance, the county voter registrar should follow steps 1
through 4 above, but substitute references to “election judge” with “county voter registrar”, including signing where the
election judge would otherwise sign on the space provided on the declaration.
