(a)
An individual applying for voter registration, or an individual preregistering to vote, shall complete a voter registration form in substantially the following form:
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UTAH ELECTION REGISTRATION FORM
Are you a citizen of the United States of America? Yes No
If you checked "no" to the above question, do not complete this form.
Will you be 18 years of age on or before election day? Yes No
If you checked "no" to the above question, are you 16 or 17 years of age and preregistering to vote? Yes No
If you checked "no" to both of the prior two questions, do not complete this form.
Name of Voter
_________________________________________________________________
First Middle Last
Utah Driver License or Utah Identification Card Number____________________________
Date of Birth ______________________________________________________
Street Address of Principal Place of Residence
____________________________________________________________________________
City County State Zip Code
Telephone Number (optional) _________________________
Email Address (optional) _____________________________________________
Last four digits of Social Security Number ______________________
Last former address at which I was registered to vote (if known)__________________________
____________________________________________________________________________
City County State Zip Code
Political Party
(a listing of each registered political party, as defined in Section
20A-8-101
and maintained by the lieutenant governor under Section
67-1a-2
, with each party's name preceded by a checkbox)
[]Unaffiliated (no political party preference) []Other (Please specify)___________________
I do swear (or affirm), subject to penalty of law for false statements, that the information contained in this form is true, and that I am a citizen of the United States and a resident of the state of Utah, residing at the above address. Unless I have indicated above that I am preregistering to vote in a later election, I will be at least 18 years of age and will have resided in Utah for 30 days immediately before the next election. I am not a convicted felon currently incarcerated for commission of a felony.
Signed and sworn
__________________________________________________________
Voter's Signature
_______________(month/day/year).
PRIVACY INFORMATION
Voter registration records contain some information that is available to the public, such as your name and address, some information that is available only to government entities, and some information that is available only to certain third parties in accordance with the requirements of law.
Your driver license number, identification card number, social security number, email address, full date of birth, and phone number are available only to government entities. Your year of birth is available to political parties, candidates for public office, certain third parties, and their contractors, employees, and volunteers, in accordance with the requirements of law.
You may request that all information on your voter registration records be withheld from all persons other than government entities, political parties, candidates for public office, and their contractors, employees, and volunteers, by indicating here:
_____ Yes, I request that all information on my voter registration records be withheld from all persons other than government entities, political parties, candidates for public office, and their contractors, employees, and volunteers.
REQUEST FOR ADDITIONAL PRIVACY PROTECTION
In addition to the protections provided above, you may request that identifying information on your voter registration records be withheld from all political parties, candidates for public office, and their contractors, employees, and volunteers, by submitting a withholding request form, and any required verification, as described in the following paragraphs.
A person may request that identifying information on the person's voter registration records be withheld from all political parties, candidates for public office, and their contractors, employees, and volunteers, by submitting a withholding request form with this registration record, or to the lieutenant governor or a county clerk, if the person is or is likely to be, or resides with a person who is or is likely to be, a victim of domestic violence or dating violence.
A person may request that identifying information on the person's voter registration records be withheld from all political parties, candidates for public office, and their contractors, employees, and volunteers, by submitting a withholding request form and any required verification with this registration form, or to the lieutenant governor or a county clerk, if the person is, or resides with a person who is, a law enforcement officer, a member of the armed forces, a public figure, or protected by a protective order or a protection order.
CITIZENSHIP AFFIDAVIT
Name:
Name at birth, if different:
Place of birth:
Date of birth:
Date and place of naturalization (if applicable):
I hereby swear and affirm, under penalties for voting fraud set forth below, that I am a citizen and that to the best of my knowledge and belief the information above is true and correct.
____________________________
Signature of Applicant
In accordance with Section
20A-2-401
, the penalty for willfully causing, procuring, or allowing yourself to be registered or preregistered to vote if you know you are not entitled to register or preregister to vote is up to one year in jail and a fine of up to $2,500.
NOTICE: IN ORDER TO BE ALLOWED TO VOTE, YOU MUST PRESENT VALID VOTER IDENTIFICATION TO THE POLL WORKER BEFORE VOTING, WHICH MUST BE A VALID FORM OF PHOTO IDENTIFICATION THAT SHOWS YOUR NAME AND PHOTOGRAPH; OR
TWO DIFFERENT FORMS OF IDENTIFICATION THAT SHOW YOUR NAME AND CURRENT ADDRESS.
FOR OFFICIAL USE ONLY
Type of I.D. ____________________________
Voting Precinct _________________________
Voting I.D. Number _____________________
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