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Minnesota Voter Registration Application
Complete lines 1 through 8. Please print clearly.
Personal Information & Quali cations
1.
Are you a U.S. citizen? Yes No
2.
Will you be at least 18 on or before the next election? Yes No
If you mark “NO” to either of these questions, DO NOT complete this form.
3.
last name or surname rst name middle name suf x
(Jr., Sr., II, III)
4.
address where you live (residence) apt. number city zip code
5.
if mail cannot be delivered to the address above, provide P.O. Box city zip code
6.
date of birth (not today’s date) school district (if known) county where you live
_ _
19
——— ———— ———————
phone number email address
_ _
——— ———— ———————
7.
mark one box and provide the number that applies to you:
I have a MN-issued driver’s license or MN ID card number:
I do not have a MN-issued driver’s license or MN ID card.
The last four digits of my Social Security Number are: XXX-XX-
I do not have a MN-issued driver’s license, a MN-issued ID card, or a Social Security Number.
Registration Updates - Are you currently registered under a different name or address?
previous last name previous rst name previous middle name
previous address where you were last registered city state zip code
Read And Sign Only If All Parts Apply To You.
8.
I certify that I:
will be at least 18 years old on election day;
am a citizen of the United States;
will have resided in Minnesota for 20 days immediately preceding election day;
maintain residence at the address given on the registration form;
am not under court-ordered guardianship in which the court order revokes my right to vote;
have not been found by a court to be legally incompetent to vote;
have the right to vote because, if I have been convicted of a felony, my felony sentence has expired (been
completed) or I have been discharged from my sentence; and
have read and understand this statement, that giving false information is a felony punishable by not more than 5
years imprisonment or a ne of not more than $10, 000, or both.
sign here
X________________________________________________ date: _____-_____- 20______
election of ce use only
Election Judge Of cial Use Only
W________
P________
SD________
Initials_______
ID With Current Address
ID Number: ________________________
MN Drivers License, Learners
Permit, MN ID Card, or Receipt
Tribal ID
Photo ID With Utility Bill or Fee Statement
Student Fee Statement or Utility Bill
(type)_____________________________
ID Number: ________________________
MN Drivers License MN ID Card
U.S. Passport U.S. Military ID
Tribal ID Student ID
Other
Vouched For
Late Notice
Previous Registration in Same Precinct
Student ID With College List
ID Number: ______________________
Hennepin
PRINT
RESET
For more information on voting, registering to vote, nding your polling place, state election results, campaign
information, or conducting elections, go to the Minnesota Secretary of State web site at www.sos.state.mn.us
or call toll free 1-877-600-VOTE (1-877-600-8683). For a TTY/TTD (deaf and hard of hearing) communication,
contact the Minnesota Relay Service at 1-800-627-3529 or 711
Deadline Information
You may pre-register to vote at any time at least 20 days before an election. If you are not able to pre-register prior to the 20 days
before an election, you must register at your polling place to vote on Election Day.
Voter registration applications must be turned in to the County Auditor or Secretary of State within 10 days of being signed.
Assistance
Large-type Minnesota Voter Registration Applications are available upon request from your County Auditor or the Of ce of the
Secretary of State.
Special assistance available to those who are elderly, have disabilities, or are in health care facilities. Contact the Secretary of
State or your County Auditor for more information.
Voter Registration Applications are available in other languages at www.sos.state.mn.us.
Your Social Security number is not public. Before providing the last 4 digits of your SSN in box 7, please read the privacy notice at
www.sos.state.mn.us/home/index.asp?page=207.
POST
OFFICE
WILL NOT
DELIVER
WITHOUT
FIRST CLASS
POSTAGE
RETURN TO: Hennepin County Elections
A600 Government Center
300 S 6th St
Minneapolis, MN 55487-0060
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