ILLINOIS VOTER REGISTRATION APPLICATION Suggested September 2017
FOR ILLINOIS RESIDENTS ONLY
TO VOTE YOU MUST:
Be a United States citizen
Be at least 18 years old (some 17 year olds may vote in the
General Primary, Consolidated Primary or Caucus)
Live in your election precinct at least 30 days
Not be convicted and incarcerated.
Not claim the right to vote anywhere else
TO VOTE IN THE NEXT ELECTION:
Mail or deliver this application to your County Clerk or Board
of Election Commissioners no later than 28 days before the
next election.
(click here for County Clerk/Election Board
listings) or go to http://www.elections.il.gov
IMPORTANT INFORMATION:
If you do not have a driver’s license, State Identification Card or
social security number, and this form is submitted by mail, and
you have never registered to vote in the jurisdiction you are now
registering in, then you must send, with this application, either (i)
a copy of a current and valid photo identification, or (ii) a copy of a
current utility bill, bank statement, government check, paycheck,
or other government document that shows the name and address
of the voter. If you do not provide the information required above,
then you will be required to provide election officials with either (i)
or (ii) described above the first time you vote in person or prior to
voting by mail.
If you change your name you must re-register.
If you register at a public service agency, any information
regarding the agency that assisted you will remain confidential as
will any decision not to register.
If you do not receive a Notice within 2 weeks of mailing or
delivering this application, call your County Clerk or Board of
Election Commissioners.
TO COMPLETE THIS FORM: SBE R-19
Box 1-If you do not have a middle name, leave blank.
Box 3-If mailing address is same as Box 2, write “same”.
Box 4-By providing an email address you agree to receive
election related notices via email.
Box 5-If you have never registered before, leave blank. If you
do not remember your former address; provide as much
information as possible.
Box 6-If you have not changed your name, leave blank.
Box 10-If you have an Illinois Driver’s License or Secretary of
State ID, check the first box and fill in the number. If you do not
have a Driver’s License or SOS ID, check the second box and fill
in the last four digits of your Social Security Number. If you do not
have a SSN, check the third box and send a copy of the
appropriate document (as described in the “Important Information”
section) along with this form.
Box 11-Read, date and personally sign your name or make
your mark in the box.
IF YOU HAVE NO STREET ADDRESS,
below describe your home: list the name of subdivision; cross
streets; roads; landmarks; mileage and/or neighbors’ names.
N
W E
S
If you have questions about completing this form, please call
the State Board of Elections at (217)782-4141 or (312)814-6440
(or webmaster@elections.il.gov).
TYPE OR PRINT CLEARLY IN BLACK OR BLUE INK
Are you a citizen of the United States of America? (check one) yes no
Will you be 18 years of age on or before the next election day OR are you currently 17 and
will be 18 by the day of the next General or Consolidated Election? (check one) yes no
If you checked “no” in response to either of these questions, then do not complete this form.
You can use this form to: (Check One) apply to register to vote in Illinois change your address change your name
1. Last Name First Name Middle Name or Initial Suffix (Circle One)
Jr. Sr. II III IV
2. Address where you live (House No., Street Name, Apt. No.) City/Village/Town Zip Code County Township
3. Mailing address (P.O. Box) City/Village/Town, State Zip Code
5. Former Registration Address: (include City and State and Zip Code) Former County
6. Former Name: (if changed)
7. Date of Birth: MM/DD/YY
9. Home telephone number
including area code (optional)
( ) -
. ID number – check the applicable box and provide the appropriate number10
IL Driver’s License or, if none, Sec. of State ID or
Last 4 digits of Social Security Number
I have none of the above-listed identification numbers.
______________________________________________________________
11.
Voter Affidavit – Read all statements and sign within the box to the right.
I swear or affirm that:
I
am a citizen of the United States;
I will be at least 18 years old on or before the next election (or the
next General or Consolidated Election);
I will have lived in the State of Illinois and in my election precinct at least
30 days as of the date of the next election;
The information I have provided is true to the best of my knowledge under
penalty of perjury. If I have provided false information, then I may be fined,
imprisoned, or if I am not a U.S. citizen, deported from or refused entry into
the United States.
This is my signature or mark in the space below.
Today’s Date: __________/__________/________
12.
If you cannot sign your name, ask the person who helped you fill in this form to print their name, address and telephone number.
N
ame of person assisting. Full Address Telephone No.
__________________________________________________________________________________________________________________________________
Return To: Kathy Michael, McLean County Clerk, 115 E Washington St, Room 102, PO Box 2400, Bloomington, IL 61702-2400
