PAGE 1
VOTER REQUEST TO CANCEL REGISTRATION
This form can only be completed by the voter. You may voluntarily cancel your voter registration
by completing this form. Please mail or deliver to your county voter registration oce. To nd a list
of these oces, please see page 2.
STE P 1:
Fill out the form
STEP 2:
Sign and date the form
STEP 3:
Mail or deliver to your county
voter registration oce
INSTRUCTIONS
False statements on this form are punishable pursuant to 18 Pa.C.S. § 4904 (relating to unsworn
falsication to authorities).
PA-DOS VRCAN 01.2021
Signature
Date
Printed Name
First name Middle name or initial
Last name Jr Sr ll lll lV (Circle if applicable)
Address
Please write
the address
where you are
registered to vote
in Pennsylvania.
Street Address (Not P.O. Box)
Apt. Number
Municipality County
City/Town State Zip Code
PA
I no longer wish to be registered to vote in Pennsylvania.
NOTICE
!
Identication
This information
will only be used to
locate your record
on le and process
your request. Your
ID information will
be condential.
Last four digits of your Social Security number X X X - X X -
PA driver’s license or PennDOT ID card number
Date of birth
MM/DD/YYYY/ /
or
Contact
Please add your
contact information
in case there are
any questions.
Phone
- -
(Optional)
Email
(Optional)
