Illinois Voter Registration Application

ILLINOIS VOTER REGISTRATION APPLICATION
TO COMPLETE THIS FORM:
FOR ILLINOIS RESIDENTS ONLY
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TO VOTE YOU MUST:
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Be a United States citizen
Be at least 18 years old (some 17 year olds may vote in the
General Primary)
Live in your election precinct at least 30 days
Not be convicted and in jail
Not claim the right to vote anywhere else
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TO VOTE IN THE NEXT ELECTION:
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Mail or deliver this application to your County Clerk or Board
of Election Commissioners no later than 28 days before the
next election. (click here for County Clerk/Election Board
listings) or go to http://www.elections.il.gov
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IMPORTANT INFORMATION:
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If you do not have a driver’s license, State Identification Card or
social security number, and this form is submitted by mail, and
you have never registered to vote in the jurisdiction you are now
registering in, then you must send, with this application, either (i)
a copy of a current and valid photo identification, or (ii) a copy of a
current utility bill, bank statement, government check, paycheck,
or other government document that shows the name and address
of the voter. If you do not provide the information required above,
then you will be required to provide election officials with either (i)
or (ii) described above the first time you vote at a voting place or
by absentee ballot.
If you change your name you must re-register.
If you register at a public service agency, any information
regarding the agency that assisted you will remain confidential as
will any decision not to register.
If you do not receive a Notice within 2 weeks of mailing or
delivering this application, call your County Clerk or Board of
Election Commissioners.
Suggested January 2014
SBE R-19
Box 1-If you do not have a middle name, leave blank.
Box 3-If mailing address is same as Box 2, write “same”.
Box 4-If you have never registered before, leave blank. If you
do not remember your former address; provide as much
information as possible.
Box 5-If you have not changed your name, leave blank.
Box 9-If you have an Illinois Driver’s License or Secretary of State
ID, check the first box and fill in the number. If you do not have a
Driver’s License or SOS ID, check the second box and fill in the
last four digits of your Social Security Number. If you do not have
a SSN, check the third box and send a copy of the appropriate
document (as described in the “Important Information” section)
along with this form.
10-Read, date and personally sign your name or make your
mark in the box.
IF YOU HAVE NO STREET ADDRESS,
below describe your home: list the name of subdivision; cross
streets; roads; landmarks; mileage and/or neighbors’ names.
N
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If you have questions about completing this form, please call
the State Board of Elections at (217)782-4141 or (312)814-6440
(or [email protected]).
TYPE OR PRINT CLEARLY IN BLACK OR BLUE INK
Are you a citizen of the United States of America?
(check one) yes
no
Will you be 18 years of age on or before the next election day OR are you currently 17 and
will be 18 by the day of the next General Election?
(check one) yes
no…..
If you checked “no” in response to either of these questions, then do not complete this form.
You can use this form to: (Check One)
apply to register to vote in Illinois
1.
Last Name
First Name
2.
Address where you live (House No., Street Name, Apt. No.)
3.
Mailing address (P.O. Box)
4.
Former Registration Address: (include City and State and Zip Code)
6.
Date of Birth: MM/DD/YY
7.
Sex (circle one)
M
F
change your address
Middle Name or Initial
(
)
-
change your name
Suffix (Circle One)
Jr. Sr. II III IV
City/Village/Town
Zip Code
City/Village/Town, State
8. Home telephone number
including area code (optional)
Office Use
Zip Code
Former County
County
Township
Email (optional)
5. Former Name: (if changed)
9. ID number – check the applicable box and provide the appropriate number
IL Driver’s License or, if none, Sec. of State ID or
Last 4 digits of Social Security Number
I have none of the above-listed identification numbers.
______________________________________________________________
10. Voter Affidavit – Read all statements and sign within the box to the right.
I swear or affirm that
• I am a citizen of the United States;
• I will be at least 18 years old on or before the next election (or the
next General Election);
• I will have lived in the State of Illinois and in my election precinct at least
30 days as of the date of the next election;
• The information I have provided is true to the best of my knowledge under
penalty of perjury. If I have provided false information, then I may be fined,
imprisoned, or if I am not a U.S. citizen, deported from or refused entry into
the United States.
This is my signature or mark in the space below.
Today’s Date: __________/__________/________
11. If you cannot sign your name, ask the person who helped you fill in this form to print their name, address and telephone number.
Name of person assisting.
Full Address
Telephone No.
__________________________________________________________________________________________________________________________________
Back of SBE No. R-19
YOUR ADDRESS
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PUT
FIRST
CLASS
STAMP
HERE
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________________________
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MAIL TO:
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CHANGE OF ADDRESS
PCT
DATE
WARD
CODE
EXPLAIN
To Election Judges
For Primary, mark
D for Democrat
R for Republican
for all other
elections markV
CITY
ZIP
COUNTY
DATE
CLERK
SUSPENSION, CANCELLATION AND REINSTATEMENT
CLERK
DATE
EXPLAIN
Voting Record
Primary
General
NonPartisan
Special
ADDRESS
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CLERK
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