Fillable Printable Form 2818

Form 2818

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AFFIDAVIT OF REQUEST TO UPDATE VOTER REGISTRATION AT THE TIME (VRG 4/12)

OF REQUESTING A BALLOT

State Form 28186 (R13 / 8-14)

Indiana Election Commission (IC 3-7-39-7; 3-7-48-5; 3-10-1-24; 3-10-11-6; 3-10-12-3.4)

INSTRUCTIONS

Questions regarding when to use this form should be directed to the County Election Board at ________________________ _______ (Insert telephone number.)

A description of the voters eligible to vote using this form is on the reverse side.

A voter must complete and sign this form in front of a notary or other person authorized to administer oaths. In the alternative, if Box 2, 3, 4 or 5 apply, the voter is permitted to make an

oral affirmation to the poll workers, who will then record the voter’s affirmation and initial below in the box designated for the voter to sign.

VOTER AFFIRMATION

To be eligible to vote using this form, a voter must make one of the affirmations below.

To the Precinct Election Board of _____________________________ Precinct _______________________ County: I, the undersigned, affirm that the information on this affidavit is true and

complete, to the best of my knowledge. I am eligible to vote in this precinct as indicated above: (you must check either Box 1, 2, 3, 4, or 5)

BOX 1: I changed my residence from one (1) precinct to another within Indiana less than 30 days before the primary/general/special election held on the _________ day

of ____________________________, 20_______; OR

BOX 2: I changed my residence from one (1) precinct to another within the same county and within the same congressional district before the

primary/general/special election held on the ___________ day of ____________________________, 20_____ __.

BOX 3: In a county using an electronic poll book, I changed my residence from one (1) address to another address within the same precinct.

BOX 4: In a county using an electronic poll book, I changed my name and desire to update my voter regist rat ion record.

BOX 5: In a county using an electronic poll book, I still reside at the address indicated on my cancelled vot er regist ration record despite t he county indicating that I moved from my

residence.

VOTER’S NAME, DATE OF BIRTH, VOTER IDENTIFICATION NUMBER AND TELEPHONE NUMBER

Last Name First Name

Middle Name

Date of Birth (mm/dd/yy)

_________/___________/_________

Voter Identification Number

(Indiana issued driver’s license number, OR state identification number; OR if

voter does not possess driver’s license, provide last 4 digits of social security number, OR state NONE if voter

does not possess any of these documents)

Telephone Number (optional)

( )

Are you a citizen of the United States of America? Yes No Will you be at least eighteen (18) years of age on or before election day? Yes No

VOTER’S PREVIOUS NAME (If voter’s name has change d, complete this section with the voter’s name before the voter changed it.)

Last Name First Name

Middle Name

VOTER’S PREVIOUS RESIDENCE ADDRESS (If voter checked BOX 1, 2, or 3 above)

Street Address City / Town State

ZIP

Code

County

VOTER’S CURRENT RESIDENCE ADDRESS (If voter checked BOX 1, 2, or 3 above)

ddress Instructions: If residing in a city or town, write the street address and any apartment or room number. If not residing in a city or town, write the mailing address and the nearest streets or

roads if not included. Example: “100 Maple Street, Apt. 12, Anytown, IN” or “R.R. 5, Box 12 (Hardscrabble Road and County Road 100 North), Anytown, I N .”

Street Address City / Town State

ZIP

Code

County

VOTER’S CURRENT MAILING ADDRESS (If Different From Residence Address)

Street Address City / Town State

ZIP Code

County

By filing this affidavit, I am requesting that my registration be updated to my new name or the residence address where I now r eside as indicat ed above (if I changed residence t o another

precinct in the same county) as soon as the update is permitt ed. I f I have changed residence from one county to another count y in Indiana, I request that my registration in the county where I

formerly resided be cancelled under IC 3-7-43-4. I understand that making a false statement on this affidavit is punishable under the penalties of perjury.

NOTE: This must be subscribed and sworn to before a person author ized to admi nister oaths withi n Indiana , such a s a notary p ubli c, judge, clerk of th e circu it

court, member of a board of voter registration, or precinct election board member.

Signature of Voter (or initials of poll clerks witnessing oral affirmation if Box

, 3, 4 or

applies)

Printed Name

Subscribed and sworn to before me, this _____ _________ day of _____________________________, 20____________.

My commission expires

(mm/dd/yyyy): __________________________ County of Residence: ___________________________ (Not required if precinct election board member)

Signature of Person Administering Oath Title

Reset Form

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The following provides guidance about when the VRG 4/12 form should be used. Questions on

when and how to use this form should be directed to the County Election Board at

_________________.

1. This form is used only for a voter who fits one of the following categories:

A. was a registered voter of Indiana who changed the voter’s residence from one (1) precinct to another within Indiana less than thirty (30) days before the primary/general/special

election and has returned to the voter’s precinct of former residence to vote, or requested an absentee ballot for the precinct of former residence;

B. was a registered voter of Indiana who changed the voter’s residence from one (1) precinct to another within the same county and within the same congressional district before the

primary/general/special election and did not update the voter registration record and has returned to the voter’s precinct of f ormer residence t o vote, or requested an absentee

ballot for the precinct of former residence;

C. in a county using an electronic poll book, is a registered voter of Indiana who moved within the same precinct;

D. in a county using an electronic poll book, is a registered voter of Indiana who desires to update the voter’s name;

E. in a county using an electronic poll book, is a voter whom the county voter registration records show formerly resided in a precinct and no longer resides in that precinct, but the

voter indicates that the voter continues to reside in the precinct.

2. The voter must complete this affidavit and sign it in the presence of a person authorized to administer oaths. In the alternative, if Box 2, 3, 4, or 5 applies, the voter may make an oral

affirmation that will be transcribed and initialed by the poll clerks.

3. If this form is executed in the County Voter Registration Office no later than 4 pm Monday before the election, the registration official must provide a copy of this form to the voter. On

election day, the voter must submit this copy to the precinct election board before the voter will be permitted to vote.

4. This form may also be executed when an application for an absentee ballot is filed with the county election board of t he county where the voter formerly resided.

5. This form may also be executed before the inspector of the precinct if the application and statement are executed on the day of the election. The inspector shall then provide the

person with a voter registration application and request that the person complete and sign the application. The inspector then returns this form and any completed voter registration

application to the county voter registration office.

6. This form may not be used in an election held only within a city or town when the voter has moved: (A) outside the city or town; or (B) into the city or town from a precinct outside the

city or town.