MassachusettsOfficial

Mail-InAgencyVoterRegistrationForm

Howtousethisform

1.Checkalltheboxesthatapplytoyou.

2.Printyourname:lastname,firstname,middlenameorinitial.

3.Printyourformername,ifapplicable.

4.Printtheaddresswhereyoulivenow:numberandstreetnameorruralroutenumberandboxnumber(donotprovideapostofficeboxnumber),apartmentnumber,cityortownandfullzipcode.Usethemap†atrightifyoucannototherwiseidentifyyouraddress.

5.Printtheaddresswhereyoureceiveallyourmail,ifitisdifferentfromtheaddress entered on#4.

6.Printyourdateofbirth:month,dayandyear.

7.Federallawrequiresthatyouprovideyourdriver’slicensenumbertoregistertovote.IfyoudonothaveacurrentandvalidMassachusettsdriver’slicense,youmustprovidethelastfourdigitsofyoursocialsecuritynumber.Ifyouhaveneither,youmustwrite“none”inthebox.

8.Itisoptionaltoprovideyourtelephonenumber.Ifyouincludeyourtele-phonenumberanddonotcheck“unlisted”itwillbeapublicrecord.

9.Checkaparty,‘noparty’orprintapoliticaldesignation(notaparty).

10.Printtheaddresswhereyouwerelastregisteredtovote.

11.Ifapersonishelpingyoubecauseyouarephysicallyunabletosignthisform,thatassistingpersonmustprinthisorhernameandaddressandhastheoptiontoprinthisorhertelephonenumber.

12.Read theoath.

13.Print today’sdate.

14.Sign yourname.

Thisformmaybemailedorhand-deliveredtoyourcityortownhall.Ifmailed,foldtheform,tapeitclosed,placeafirstclassstamponit,printyourcityortownnameandzipcodeforthatcityortownhallanddropintoanymailbox.

Printallinformationinblackink.Followaboveinstructionsforproperdelivery.

WilliamFrancisGalvin

SecretaryoftheCommonwealth

1 / Checkallthatapply:AreyouaCitizenoftheUnitedStatesofAmerica?■Yes■No
Willyoube18yearsofageorolderonorbeforeElectionDay?■Yes■NoNOTE:Ifyouchecked“no”toeitherofthesequestions,donotcompletethisform.
2 / Fullname:last namefirst nameMiss Ms. Mrs.Mr. / middle name orinitial / Jr. Sr. II III IV
(circle one ifappropriate)
3 / Formername(ifapplicable):lastnamefirst nameMiss Ms. Mrs.Mr. / middle name orinitial / Jr. Sr. II III IV
(circle one ifappropriate)
4 / Address where you live now (streetnumber,streetname,ruralroutenumberand
street number / street name / rural route number and boxnumberapartmentnumbercity ortown / boxnumber): / zip code +4-digit
5 / Addresswhereyoureceiveallyourmail(ifdifferentfrom#4):
street number / street name / rural route number and boxnumberapartmentnumbercity ortown / zip code +4-digit
6 / Date ofbirth:
monthdayyear / 7 / Identification#:
license # or last four digits of your Social Security# / 8 / Telephone(optional):■Checkifunlisted
()
9 / Partyenrollmentordesignation(checkone): ■Democratic ■Republican ■Green-Rainbow
■UnitedIndependentParty■NoParty(unenrolled)■PoliticalDesignation(notapoliticalparty):
10 / Addressatwhichyouwerelastregisteredtovote:
streetnumber/streetname/ruralroutenumberandboxnumber/postofficeboxapartment number / city ortown / statezip code +4-digit
11 / Iftheapplicantisunabletosignthisform,givethename,addressandtelephonenumber(optional)ofthepersonhelpingtheapplicant:
nameaddresstelephonenumber(optional)
12 / Iherebyswear(affirm)thatIamthepersonnamedabove,thattheaboveinformationistrue,thatIAMACITIZENOFTHEUNITEDSTATES,thatIamnotapersonunderaguardianshipwhichprohibitsmyregisteringtovote,thatIamnottemporarilyorpermanentlydisqualifiedbylawfromvotingbecauseofcorruptpracticesinrespecttoelections,thatIamnotcurrentlyincarceratedforafelonyconviction,andthatIconsiderthisresidencetobemyhome.Signedunderthepenaltyofperjury.
13 / Today’s date:monthdayyear 14 Signed: Sign your namehere. / Designation: AAB
Agency

Check tomakesure that youhavecompletedall

theinformationonthevoterregistrationaffidavit ontheoppositeside!

ThisformmustbereceivedbythelocalBoardofRegistrarsorElectionCommissionorpostmarkedonorbeforethedeadlineforvoterregistration(listed below) for that election, primary, preliminary or townmeeting.

DEADLINES FOR VOTERREGISTRATION

To participatein...Youmustregister...

stateprimariesstateelections

city and townpreliminariescity and townelections

regularly scheduled townmeetings

at least 20 daysbefore

special townmeetingsatleast10daysbefore

If you do not hear from your local election officials in 2 or 3 weeks, please callthem!

Fold along dottedline.