Form B-58 IND "Individual Change of Address/Voter Registration Application" - Connecticut

What Is Form B-58 IND?

This is a legal form that was released by the Connecticut Department of Motor Vehicles - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2017;
  • The latest edition provided by the Connecticut Department of Motor Vehicles;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form B-58 IND by clicking the link below or browse more documents and templates provided by the Connecticut Department of Motor Vehicles.

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Download Form B-58 IND "Individual Change of Address/Voter Registration Application" - Connecticut

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STATE OF CONNECTICUT
FOR DMV INTERNAL USE ONLY
B-58 IND Rev. 12-2017
DEPARTMENT OF MOTOR VEHICLES
LICENSE/ID
INDIVIDUAL CHANGE OF ADDRESS/VOTER REGISTRATION APPLICATION
CHANGES COMPLETED
REGISTRATION
INSTRUCTIONS: (Please print in ink or type): You are only required to fill in the sections applicable to your needs.
CHANGES COMPLETED
Please mail completed form to: DMV Change of Address Unit, 60 State Street, Wethersfield, CT 06161-1015
NAME (Last, First, Middle)
BIRTH DATE
OPERATOR LICENSE/ID NUMBER
SIGNATURE
DATE SIGNED
TELEPHONE NUMBER
X
** FORMS WITHOUT A NAME, OPERATOR LICENSE/ID, BIRTH DATE, AND SIGNATURE WILL NOT BE PROCESSED **
SECTION 1
- NEW RESIDENCE ADDRESS - This must be a Connecticut Address.
Unless listed in SECTION 3 below, all registrations assigned to your current residence address will automatically be reassigned by the DMV to your new
residence address for you.
Street and if applicable unit/apartment number
City
State
Zip Code
CT
06
Check here if this change of residence address is NOT for voter registration purposes
If you are already a registered voter and you do not check this box, your address will be changed in your voter record as follows:
(1) If your new residence address is in the same city/town, your address will be updated with the registrar in your city/town; or
(2) if your new residence address is in a different city/town, this form will be used for voter registration in your new city/town.
SECTION 2
- MAILING ADDRESS - Only required if your mailing address is different from your residence address.
Street and if applicable unit/apartment number
City
State
Zip Code
SECTION 3
- CHANGE VEHICLE/BOAT ADDRESS - These must be Connecticut Addresses.
List below the location of any vehicle/boat you DO NOT want the DMV to change to your new residence address.
DMV will only send mail to your residence address.
License Plate or Boat #
Street and if applicable unit/apartment number
License Plate or Boat #
Street and if applicable unit/apartment number
City
State
Zip Code
City
State
Zip Code
06
06
CT
CT
License Plate or Boat #
Street and if applicable unit/apartment number
License Plate or Boat #
Street and if applicable unit/apartment number
City
State
Zip Code
City
State
Zip Code
06
06
CT
CT
SECTION 4
- EMAIL ADDRESS
Delete Email Address - By checking this box, all future registration renewals will again be printed and mailed to you.
New Email Address:
By checking this box and entering a New Email address, all future registration renewals will be electronically sent to you at
this email address. Paper registration renewals will no longer be mailed to you.
SECTION 5
- ORGAN AND TISSUE DONOR
I consent to organ and tissue donation and wish to be in the donor registry
I no longer wish to be in the donor registry
SECTION 6 - VOTER REGISTRATION APPLICATION - You must complete SECTION 1 above first.
* You are registering to vote for the first time.
Complete this section if: OR
* You are already a registered voter and would like to change your political party affiliation.
TO REGISTER TO VOTE YOU MUST BE: A United States citizen; at least 18 years of age (by election day); and a resident of Connecticut and the city or
town where you are applying to register to vote.
Are you a citizen of the United States of America?
YES
NO
Will you be 18 years of age on or before election day?
YES
NO
If you checked "NO" in response to either of these questions, do NOT complete below this line as you cannot register to vote.
NAME OF PARTY:
YES
DEMOCRATIC
REPUBLICAN
OTHER:
Do you wish to enroll
in a political party?
I DO NOT WISH TO ENROLL IN A PARTY AT THIS TIME AND WILL BE REGISTERED AS UNAFFILIATED
NO
Note: Declaring a party enables you to vote in the party's primary election, which is open only to party members.
You may later choose to switch enrollment to or from a political party.
LEAVING THIS SECTION BLANK WILL AUTOMATICALLY RESULT IN SELECTING UNAFFILIATED
VOTER DECLARATION - I swear or affirm under penalty of perjury that:
*
I am a U.S. Citizen
*
I have not been convicted of a disfranchising felony, or if so, I am eligible to register to vote
*
I live in Connecticut at the address shown
*
I am at least 17 years old and will be 18 years old on or before election day
SIGNATURE OF APPLICANT**
TODAY'S DATE
** Voter registrations without a
signature will not be processed.
X
The information that I have provided is true to the best of my knowledge under penalty of perjury. If I have provided false information, I may be
subject to a fine or imprisonment or both under federal or state laws.
By signing this Voter Declaration, I agree to allow the signature from my license record to be used as the signature on my voter registration record.
STATE OF CONNECTICUT
FOR DMV INTERNAL USE ONLY
B-58 IND Rev. 12-2017
DEPARTMENT OF MOTOR VEHICLES
LICENSE/ID
INDIVIDUAL CHANGE OF ADDRESS/VOTER REGISTRATION APPLICATION
CHANGES COMPLETED
REGISTRATION
INSTRUCTIONS: (Please print in ink or type): You are only required to fill in the sections applicable to your needs.
CHANGES COMPLETED
Please mail completed form to: DMV Change of Address Unit, 60 State Street, Wethersfield, CT 06161-1015
NAME (Last, First, Middle)
BIRTH DATE
OPERATOR LICENSE/ID NUMBER
SIGNATURE
DATE SIGNED
TELEPHONE NUMBER
X
** FORMS WITHOUT A NAME, OPERATOR LICENSE/ID, BIRTH DATE, AND SIGNATURE WILL NOT BE PROCESSED **
SECTION 1
- NEW RESIDENCE ADDRESS - This must be a Connecticut Address.
Unless listed in SECTION 3 below, all registrations assigned to your current residence address will automatically be reassigned by the DMV to your new
residence address for you.
Street and if applicable unit/apartment number
City
State
Zip Code
CT
06
Check here if this change of residence address is NOT for voter registration purposes
If you are already a registered voter and you do not check this box, your address will be changed in your voter record as follows:
(1) If your new residence address is in the same city/town, your address will be updated with the registrar in your city/town; or
(2) if your new residence address is in a different city/town, this form will be used for voter registration in your new city/town.
SECTION 2
- MAILING ADDRESS - Only required if your mailing address is different from your residence address.
Street and if applicable unit/apartment number
City
State
Zip Code
SECTION 3
- CHANGE VEHICLE/BOAT ADDRESS - These must be Connecticut Addresses.
List below the location of any vehicle/boat you DO NOT want the DMV to change to your new residence address.
DMV will only send mail to your residence address.
License Plate or Boat #
Street and if applicable unit/apartment number
License Plate or Boat #
Street and if applicable unit/apartment number
City
State
Zip Code
City
State
Zip Code
06
06
CT
CT
License Plate or Boat #
Street and if applicable unit/apartment number
License Plate or Boat #
Street and if applicable unit/apartment number
City
State
Zip Code
City
State
Zip Code
06
06
CT
CT
SECTION 4
- EMAIL ADDRESS
Delete Email Address - By checking this box, all future registration renewals will again be printed and mailed to you.
New Email Address:
By checking this box and entering a New Email address, all future registration renewals will be electronically sent to you at
this email address. Paper registration renewals will no longer be mailed to you.
SECTION 5
- ORGAN AND TISSUE DONOR
I consent to organ and tissue donation and wish to be in the donor registry
I no longer wish to be in the donor registry
SECTION 6 - VOTER REGISTRATION APPLICATION - You must complete SECTION 1 above first.
* You are registering to vote for the first time.
Complete this section if: OR
* You are already a registered voter and would like to change your political party affiliation.
TO REGISTER TO VOTE YOU MUST BE: A United States citizen; at least 18 years of age (by election day); and a resident of Connecticut and the city or
town where you are applying to register to vote.
Are you a citizen of the United States of America?
YES
NO
Will you be 18 years of age on or before election day?
YES
NO
If you checked "NO" in response to either of these questions, do NOT complete below this line as you cannot register to vote.
NAME OF PARTY:
YES
DEMOCRATIC
REPUBLICAN
OTHER:
Do you wish to enroll
in a political party?
I DO NOT WISH TO ENROLL IN A PARTY AT THIS TIME AND WILL BE REGISTERED AS UNAFFILIATED
NO
Note: Declaring a party enables you to vote in the party's primary election, which is open only to party members.
You may later choose to switch enrollment to or from a political party.
LEAVING THIS SECTION BLANK WILL AUTOMATICALLY RESULT IN SELECTING UNAFFILIATED
VOTER DECLARATION - I swear or affirm under penalty of perjury that:
*
I am a U.S. Citizen
*
I have not been convicted of a disfranchising felony, or if so, I am eligible to register to vote
*
I live in Connecticut at the address shown
*
I am at least 17 years old and will be 18 years old on or before election day
SIGNATURE OF APPLICANT**
TODAY'S DATE
** Voter registrations without a
signature will not be processed.
X
The information that I have provided is true to the best of my knowledge under penalty of perjury. If I have provided false information, I may be
subject to a fine or imprisonment or both under federal or state laws.
By signing this Voter Declaration, I agree to allow the signature from my license record to be used as the signature on my voter registration record.