If you are not registered to vote where you live now, would you like to
apply to register to vote here today?
Already registered. I am registered to vote at my current residence address.
Yes. I would like to register to vote. (Please fill out the attached voter
No. I do not want to register to vote.
NOTE: IF YOU DO NOT CHECK A BOX, YOU WILL BE CONSIDERED TO HAVE
DECIDED NOT TO REGISTER TO VOTE AT THIS TIME. YOU MAY TAKE THE
ATTACHED VOTER REGISTRATION FORM TO REGISTER AT YOUR
Applicant Name Date
1. Applying to register or declining to register to vote will not affect the amount of
assistance that you will be provided by this agency.
2. If you would like help in 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 voter registration
form in private.
3. If you believe that someone has interfered with your right to register or to decline to
register to vote, your right to privacy in deciding whether to register or in applying to
register to vote, or your right to choose your own political party preference or other
political preference, you may file a complaint with the Secretary of State by calling toll-
free (800) 345-VOTE (8683) or you may write to: Secretary of State, 1500 - 11
Sacramento, CA, 95814. For more information on elections and voting, please visit the
Secretary of State’s website at www.sos.ca.gov.
01/13 NVRA Voter Preference Form