Indiana Voter Registration Application

INDIANA VOTER REGISTRATION APPLICATION
(VRG-7)
State Form 50504 (R5/12-05)
Indiana Election Commission
You can use this application to:
Apply to register to vote in Indiana or
Change your name and address on your voter registration record.
To register you must:
Be a citizen of the United States;
Be at least 18 years old on the day of the next general or municipal election;
Have lived in your precinct for at least 30 days before the next election (except for
certain military voters); and
Not currently be imprisoned after being convicted of a crime.
If you move:
You must transfer your registration whenever you move out of your precinct.
You may use this application to transfer your registration. You may mail or hand deliver
the completed application to your county registration office.
To complete this form:
FILL IN ALL THE BOXES THAT APPLY TO YOU IN BLUE OR BLACK INK
Box 4: Residence Address Type or print the address where you live (number, street,
apartment number, city/town, and ZIP code). If your address is a rural route or star route,
be sure to include the box number. If this address does not have a street number, draw a
map in Box 15.
Box 5: Mailing Address If this address is the same as Box 4, just print “SAME” in this box.
Box 6: Previous Voter Registration Address If you have been registered previously,
please list your most recent registration address.
Boxes 8 and 9: These questions are optional. Your application will be processed even if
you do not answer these questions.
Box 10: Identification Documentation If you are registering to vote in Indiana for the first
time, and you are sending this application by mail, you must provide identification
documentation. Identification may include a current and valid photo id, current utility bill,
bank statement, government check, paycheck, or government document that shows the
name and address of the voter. You may include a copy of your identification with this
application. Do not mail an ORIGINAL copy of your document! If you do not provide
identification with this application or to the county voter registration office before election
day, you will be asked for it the first time you vote.
Box 11:If you check “no” in response to the question in Box 11, you may not complete this
application.
Box 12: The question in Box 12 requires a person to be at least 18 years of age by the
next general or municipal election. If you check “no” in response to the question in Box 12,
you may not complete this application.
Box 13: Voter Identification Number In Box 13, you are required to provide your Indiana
driver’s license number as issued by the Indiana Bureau of Motor Vehicles. If you do not
have an Indiana driver’s license, provide the last four digits of your social security number.
If you do not have an Indiana driver’s license number, or a social security number, a voter
identification number will be assigned to you.
Box 14: If this is an application for a name change, provide your previous name in Box 14.
If you have not changed your name, skip this question.
Box 15: Skip this question if the address where you live has a street name and number
(such as 100 Maple Street). If you have a rural route or star route address, please draw a
simple map that shows the nearest crossroads or street intersection and where your
residence is located. If you do not live in a house or other building, please draw a map that
shows where you usually sleep and the nearby streets.
Box 16: This application cannot be processed without the voter’s original signature
in this section. DO NOT FAX THIS FORM AFTER COMPLETING IT.
Registration Deadlines: In order to be processed for the next election, this application
must be postmarked or hand delivered to your county voter registration office no later than
29 days before the next election. If your county registration office receives this application
after that day, you will be unable to vote in the next election. If you miss this deadline, your
registration application will be processed when registration reopens. Some military voters
and their family members can register until noon on election day. Contact your county voter
registration office for information if you may qualify to do so.
Acknowledgment Notice: You will be sent a notice from your county voter registration
office that acknowledges receipt of your voter registration application. The notice informs
you whether your registration application was approved by the county voter registration
office. The notice may identify where you can vote. If your registration application is
incomplete, you may be contacted and asked to provide additional information. If you have
not received an acknowledgment notice within 30 days of filing this application you should
contact your county voter registration office.
Questions? Call your county voter registration office or the Indiana Election Division for
assistance.
Indiana Election Division
302 West Washington Street, Room E204
Indianapolis, Indiana 46204-2743
Telephone: 317-232-3939 or Toll-free Indiana only: 800-622-4941
www.in.gov/sos/elections
[email protected]
If Not Typed, Please Print in Blue or Black Ink
1
3
Check boxes
that apply:
New registration
Address change (See Box 6)
Name change (See Box 14)
Last Name
Indiana county where you live:
2
COUNTY
USE ONLY
Date processed
First Name
Gender
Female
Male
Residence Address (No Post Office Boxes)
Township/Precinct
County Tracking Number
Middle Name or Initial
Suffix
Jr. Sr. II III IV
Apt. No.
State
City / Town
4
Zip Code
IN
Mailing Address, if different from Box 4, if same, print “SAME”
Apt. No.
City / Town
State
Zip Code
Apt. No.
City / Town
State
Zip Code
5
Previous Voter Registration Address
County
6
Date of Birth (mm/dd/yy)
7
11
Are you a citizen of the United States
of America?
Yes
14
Telephone number (If available)
E-mail (If available)
8
9
12
Will you be at least 18 years of age on
or before election day?
No
Yes
If you have changed your name, what was your name
before you changed it? If you have not changed
your name, skip this question.
10
13
No
Last Name
First Name
Driver’s License Number
Social Security Number
None
Middle Name or Initial
Suffix
Jr. Sr. II III IV
Map/Diagram: If your residence has no address, street number or name (such
as 100 Maple Street), please draw a map showing where your residence is
located, include roads and landmarks. Otherwise, skip this question.
I authorize my voter registration at any other address to be cancelled. I swear or affirm that:
I am a citizen of the United States.
I will be at least 18 years of age at the next general or municipal election.
I will have lived in my precinct for at least 30 days before the next election.
I am not currently in prison after being convicted of a crime.
All the above information and all other statements on this form are true.
I understand that if I sign this statement knowing that it is not true I am committing perjury and
can be fined up to $10,000, jailed for up to three years or both.
N
15
W
Voter Identification Number
Provide your 10-digit Indiana issued driver’s
license number. If you do not possess an
Indiana driver’s license, then provide the last
4 digits of your social security number here.
Are you including identification documentation?
(See instructions for Box 10 above.)
Yes
No
E
16
Signature of Applicant
Date
If applicant is unable to fill out the application due to disability, the person who helped the applicant with this
application lists their name, address and telephone number in the box below. (Telephone number is optional.)
Name
Address
City/Town
Telephone Number (optional)
S
50504
Indiana County Voter Registration Offices
Sign and Mail this Completed Voter Registration Application to the county where you live or to the Indiana Election Division
ADAMS
Adams Co. Circuit Court Clerk
112 S. Second
P.O. Box 189
Decatur, IN 46733 – 0189
(260) 724-5300 ext. 2110
ALLEN
Allen Co. Board of Voter Registration
City County Building
1 East Main Street, Room 132
Fort Wayne, IN 46802 - 1809
(260) 449-7154
BARTHOLOMEW
Bartholomew Co. Circuit Court Clerk
P.O. Box 924
Columbus, IN 47202 - 0924
(812) 379-1604
BENTON
Benton Co. Circuit Court Clerk
706 E. 5th Street
Suite 37
Fowler, IN 47944 - 1556
(765) 884-0930
BLACKFORD
Blackford Co. Circuit Court Clerk
110 W. Washington St.
Hartford City, IN 47348 - 2298
(765) 348-7217
BOONE
Boone Co. Circuit Court Clerk
Room 212, Courthouse Square
Lebanon, IN 46052 - 2100
(765) 483-5251
BROWN
Brown Co. Circuit Court Clerk
P.O. Box 85
Nashville, IN 47448 - 0085
(812) 988-5511
CARROLL
Carroll Co. Circuit Court Clerk
101 W. Main St.
Delphi, IN 46923
(765) 564-6795
DUBOIS
Dubois Co. Circuit Court Clerk
One Courthouse Square, Room 104
Jasper, IN 47546 -3058
(812) 481-7035
JAY
Jay Co. Circuit Court Clerk
120 North Court
Portland, IN 47371 – 2195
(260) 726-4951
NOBLE
Noble Co. Circuit Court Clerk
101 North Orange Street
Albion, IN 46701 – 1092
(260) 636-2736
ELKHART
Elkhart Co. Board of Voter Registration
County Office Bldg. Rm. L4
117 North 2nd Street
Goshen, IN 46526 - 3243
(574) 535-6774
JEFFERSON
Jefferson Co. Circuit Court Clerk
Courthouse, Room 203
300 East Main Street
Madison, IN 47250 - 3594
(812) 265-8926
OHIO
Ohio Co. Circuit Court Clerk
P.O. Box 185
Rising Sun, IN 47040 - 0185
(812) 438-2610
FAYETTE
Fayette Co. Circuit Court Clerk
P.O. Box 607
Connersville, IN 47331 - 0607
(765) 825-1813
JENNINGS
Jennings Co. Circuit Court Clerk
P.O. Box 385
Vernon, IN 47282 - 0385
(812) 352-3080
ORANGE
Orange Co. Circuit Court Clerk
1 Court Street
Orange County Courthouse
Paoli, IN 47454 - 9632
(812) 723-2649
FLOYD
Floyd Co. Circuit Court Clerk
311 W. 1st St. Rm. 235
P.O. Box 1056
New Albany, IN 47150
(812) 948-5419
JOHNSON
Johnson Co. Board of Voter Registration
P.O. Box 451
Franklin, IN 46131 - 0451
(317) 346-4466
OWEN
Owen Co. Circuit Court Clerk
P.O. Box 146
Spencer, IN 47460 - 0146
(812) 829-5028
KNOX
Knox Co. Circuit Court Clerk
101 North 7th Street
Vincennes, IN 47591 - 2022
(812) 895-4928
PARKE
Parke Co. Circuit Court Clerk
116 West High Street
Room 204
Rockville, IN 47872 - 1781
(765) 569-5132
FOUNTAIN
Fountain Co. Circuit Court Clerk
P.O. Box 183
Covington, IN 47932
(765) 793-2192
FRANKLIN
Franklin Co. Circuit Court Clerk
459 Main Street
Brookville, IN 47012 - 1486
(765) 647-5111
FULTON
Fulton Co. Circuit Court Clerk
815 Main Street
Rochester, IN 46975 - 0524
(574) 223-7713
GIBSON
Gibson Co. Circuit Court Clerk
P.O. Box 630
Princeton, IN 47670 - 0630
(812) 385-2541
CASS
Cass Co. Circuit Court Clerk
200 Court Park, Room 103
Logansport, IN 46947 - 3192
(574) 753-7870
GRANT
Grant Co. Board of Voter Registration
Courthouse, Suite B-9
101 E. 4th Street
Marion, IN 46952 - 4055
(765) 664-9880
CLARK
Clark Co. Circuit Court Clerk
501 E. Court Avenue
Jeffersonville, IN 47130-4090
(812) 285-6329
GREENE
Greene Co. Circuit Court Clerk
P.O. Box 229
Bloomfield, IN 47424 - 0229
(812) 384-2015
CLAY
Clay Co. Circuit Court Clerk
P.O. Box 33
609 E. National Ave.
Brazil, IN 47834 - 0033
(812) 448-9023
HAMILTON
Hamilton Co. Board of Voter Registration
1 Hamilton County Square
Suite 13
Noblesville, IN 46060 - 2230
(317) 776-9632
CLINTON
Clinton Co. Circuit Court Clerk
265 Courthouse Square
Frankfort, IN 46041 - 1993
(765) 659-6337
HANCOCK
Hancock Co. Board of Voter Registration
9 East Main Street
Room 202
Greenfield, IN 46140 - 2320
(317) 462-1171
CRAWFORD
Crawford Co. Circuit Court Clerk
P.O. Box 375
Court St.
English, IN 47118 - 0375
(812) 338-2565
HARRISON
Harrison Co. Circuit Court Clerk
Courthouse, Room 203
300 North Capitol Avenue
Corydon, IN 47112 - 1155
(812) 738-8790
DAVIESS
Daviess Co. Circuit Court Clerk
200 E. Walnut Street
P.O. Box 739
Washington, IN 47501 - 0739
(812) 254-8679
HENDRICKS
Hendricks Co. Circuit Court Clerk
P.O. Box 599
Danville, IN 46122 - 0599
(317) 745-9313
DEARBORN
Dearborn Co. Circuit Court Clerk
215 W. High Street
Lawrenceburg, IN 47025 - 1909
(812) 537-8869
HENRY
Henry Co. Board of Voter Registration
P.O. Box B
New Castle, IN 47362 - 1044
(765) 529-3000
DECATUR
Decatur Co. Circuit Court Clerk
150 Courthouse Square
Suite 244
Greensburg, IN 47240 - 2080
(812) 663-8223
HOWARD
Howard Co. Board of Voter Registration
104 North Buckeye Street, Room 106
Kokomo, IN 46901 - 9004
(765) 456-2219
DEKALB
Dekalb Co. Circuit Court Clerk
P.O. Box 230
100 S. Main Street
Auburn, IN 46706 - 0230
(260) 925-9787
DELAWARE
Delaware Co. Board of Voter Registration
100 West Main Street, Room 200
Muncie, IN 47305 - 2836
(765) 747- 7812
HUNTINGTON
Huntington Co. Circuit Court Clerk
P.O. Box 228
201 North Jefferson Street
Huntington, IN 46750
(260) 358-4820
JACKSON
Jackson Co. Circuit Court Clerk
111 South Main Street
P.O. Box 122
Brownstown, IN 47220 -0122
(812) 358-6120
JASPER
Jasper Co. Circuit Court Clerk
115 West Washington
Rensselaer, IN 47978
(219) 866-4929
KOSCIUSKO
Kosciusko Co. Circuit Court Clerk
121 North Lake Street
Warsaw, IN 46580 - 2788
(574) 372-2332
LAGRANGE
LaGrange Co. Circuit Court Clerk
105 North Detroit Street
LaGrange, IN 46761 - 1801
(260) 449-6358
LAKE
Lake Co. Board of Voter Registration
2293 North Main Street, Suite 16
Crown Point, IN 46307
(219) 755-3795
LAPORTE
LaPorte Co. Board of Voter Registration
813 Lincolnway, Suite 103
LaPorte, IN 46350 - 3401
(219) 326-6808 ext. 250
LAWRENCE
Lawrence Co. Circuit Court Clerk
916 15th St. Room 31
Bedford, IN 47421 - 3800
(812) 277-2036
MADISON
Madison Co. Board of Voter Registration
th
16 East 9 Street, Suite 208
Anderson, IN 46016 - 1588
(765) 641-9657
MARION
Marion Co. Board of Voter Registration
200 East Washington, W131
Indianapolis, IN 46204 - 3355
(317) 327-5040
MARSHALL
Marshall Co. Circuit Court Clerk
211 West Madison Street
Plymouth, IN 46563 - 1762
(574) 935-8713
MARTIN
Martin Co. Circuit Court Clerk
111 Main St.
P.O. Box 120
Shoals, IN 47581
(812) 247-3651
MIAMI
Miami Co. Circuit Court Clerk
P.O. Box 184
Peru, IN 46970 - 0184
(765) 472-3901 ext. 226
MONROE
Monroe Co. Board of Voter Registration
301 North College Avenue, Room 202
Bloomington, IN 47401 - 3865
(812) 349-2690
MONTGOMERY
Montgomery Co. Circuit Court Clerk
100 East Main Street, Room 203
P.O. Box 768
Crawfordsville, IN 47933 - 0768
(765) 364-6437
MORGAN
Morgan Co. Circuit Court Clerk
P.O. Box 1556
Martinsville, IN 46151 - 1556
(765) 342-1029
NEWTON
Newton Co. Circuit Court Clerk
P.O. Box 49
Kentland, IN 47951 - 0049
(219) 474-6081
PERRY
Perry Co. Circuit Court Clerk
2219 Payne Street
Tell City, IN 47586 - 2832
(812) 547-3741
PIKE
Pike Co. Circuit Court Clerk
801 Main St. 2nd Floor
Petersburg, IN 47567 - 1298
(812) 354-6025
PORTER
Porter Co. Board of Voter Registration
Administration Center
Suite 105
155 Indiana Avenue
Valparaiso, IN 46383 - 5555
(219) 465-3484
POSEY
Posey Co. Circuit Court Clerk
P.O. Box 606
Mt. Vernon, IN 47620 - 0606
(812) 838-1339
PULASKI
Pulaski Co. Circuit Court Clerk
112 East Main
Room 230
Winamac, IN 46966 - 1394
(574) 946-6461
PUTNAM
Putnam Co. Circuit Court Clerk
P.O. Box 546
Greencastle, IN 46135 - 0546
(765) 655-1538
RANDOLPH
Randolph Co. Circuit Court Clerk
P.O. Box 230
Winchester, IN 47394 - 0230
(765) 584-4717
RIPLEY
Ripley Co. Circuit Court Clerk
P.O. Box 177
115 N. Main Street
Versailles, IN 47042
(812) 689-4783
RUSH
Rush Co. Circuit Court Clerk
101 East 2nd Street
P.O. Box 429
Rushville, IN 46173 - 0429
(765) 932-4522
ST. JOSEPH
St. Joseph Co. Board of Voter Registration
City-County Building, 4th Floor
227 West Jefferson Boulevard
South Bend, IN 46601 - 1871
(574) 235-9520
SCOTT
Scott Co. Circuit Court Clerk
1 East McClain Avenue
Scottsburg, IN 47170 - 1885
(812) 752-8420
SHELBY
Shelby Co. Circuit Court Clerk
P.O. Box 198
Shelbyville, IN 46176 - 0198
(317) 392-6324
SPENCER
Spencer Co. Circuit Court Clerk
P.O. Box 12
200 Main Street
Rockport, IN 47635 - 0012
(812) 649-6017
STARKE
Starke Co. Circuit Court Clerk
Courthouse, Room E
53 East Washington Street
Knox, IN 46534 - 1197
(574) 772-9160
STEUBEN
Steuben Co. Circuit Court Clerk
55 South Public Square
Angola, IN 46703 – 1945
(260) 668-1000 ext. 2220
SULLIVAN
Sullivan Co. Circuit Court Clerk
Courthouse, Room 370
100 Courthouse Square
Sullivan, IN 47882 - 0370
(812) 268-4657
SWITZERLAND
Switzerland Co. Circuit Court Clerk
Courthouse
212 West Main
Vevay, IN 47043 - 1180
(812) 427-3175
TIPPECANOE
Tippecanoe Co. Board of Voter
Registration
301 Main Street
Lafayette, IN 47901 - 1360
(765) 423-9316
TIPTON
Tipton Co. Circuit Court Clerk
101 East Jefferson
Tipton, IN 46072 - 1901
(765) 675-2795
UNION
Union Co. Circuit Court Clerk
26 West Union Street
Liberty, IN 47353 - 1396
(765) 458-6121
VANDERBURGH
Vanderburgh Co. Voter Registration
Civic Center Complex, Room 106
1 NW Martin Luther King Jr. Boulevard
Evansville, IN 47708 - 1828
(812) 435-5224
VERMILLION
Vermillion Co. Circuit Court Clerk
P.O. Box 10
Newport, IN 47966 - 0008
(765) 492-3500
VIGO
Vigo Co. Board of Voter Registration
Courthouse, Room 3
33 South 3rd Street
Terre Haute, IN 47808 - 3472
(812) 462-3393
WABASH
Wabash Co. Circuit Court Clerk
One West Hill Street, Suite 6
Wabash, IN 46992 - 3175
(260) 563-0661 ext. 58
WARREN
Warren Co. Circuit Court Clerk
125 North Monroe Street
Suite 11
Williamsport, IN 47993 - 1198
(765) 762-2834
WARRICK
Warrick Co. Circuit Court Clerk
1 County Square
Suite 220
Boonville, IN 47601 - 1594
(812) 897-6161
WASHINGTON
Washington Co. Circuit Court Clerk
99 Public Square North
Salem, IN 47167 - 2098
(812) 883-5748
WAYNE
Wayne Co. Circuit Court Clerk
301 E. Main Street
Richmond, IN 47374
(765) 973-9304
WELLS
Wells Co. Circuit Court Clerk
102 West Market Street
Suite 201
Bluffton, IN 46714 - 2091
(260) 824-6480
WHITE
White Co. Circuit Court Clerk
P.O. Box 350
Monticello, IN 47960 - 0350
(574) 583-1531
WHITLEY
Whitley Co. Circuit Court Clerk
101 West Van Buren Street
Columbia City, IN 46725 - 2087
(260) 248-3164