Form VRG-11 (State Form 46965) "Indiana County Voter Registration Application" - Indiana

What Is Form VRG-11 (State Form 46965)?

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

Form Details:

  • Released on September 1, 2013;
  • The latest edition provided by the Indiana Secretary of State;
  • 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 VRG-11 (State Form 46965) by clicking the link below or browse more documents and templates provided by the Indiana Secretary of State.

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Download Form VRG-11 (State Form 46965) "Indiana County Voter Registration Application" - Indiana

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INDIANA COUNTY VOTER REGISTRATION
(VRG-11)
APPLICATION
For election info, see:
www.indianavoters.com
State Form 46965 (R12 / 9-13)
Indiana Election Commission
Acknowledgment Notice: You will be sent a notice from
You can use this application to: Apply to register to vote
Box 4: Residence Address Print the address where you
your county voter registration office acknowledging receipt
in Indiana or change your name and address on your
live. If your address is a rural route, include the box number.
of your application. The notice informs you whether your
record or transfer your registration if you move out of your
If your residence has no address or street number, write a
application was approved by the county voter registration
precinct.
short description of its location in Box 4 or attach a map.
office. If your application is incomplete, you will be asked
To register you must: Be a citizen of the United States; be
Boxes 10 or 11: If you check “no” in response to either
to provide additional information. If you do not receive a
at least 18 years old on the day of the next general or
question in Boxes 10 or 11, do not complete this
notice within 30 days of filing this application, contact your
municipal election; have lived in your precinct for at least
application.
county voter registration office.
30 days before the next election; and not currently be
Box 12: Voter Identification Number: You are required
imprisoned after being convicted of a crime.
to provide your Indiana driver’s license number as issued
Indiana Election Division
If you are registering to vote in Indiana for the first time, and
by the Indiana Bureau of Motor Vehicles. If you do not
302 West Washington Street, Room E204
send this application by mail, you must provide additional
have an Indiana driver’s license, provide the last four
Indianapolis, IN 46204-2743
residence documentation before voting. If the county is
digits of your social security number. If you do not have
Telephone: (317) 232-3939
able to match your driver’s license number or social security
an Indiana driver’s license number, or a social security
Toll-free (Indiana only): (800) 622-4941
number with an existing Indiana identification record
number, you must indicate “None”.
www.in.gov/sos/elections
bearing the same number, name and date of birth you
Box 14: This application cannot be processed without
provide on the application, you have met the requirement.
the voter’s original signature in this section.
APPLICANT’S RECEIPT FROM INDIVIDUAL ACCEPTING
You can also meet this requirement by submitting proof of
Registration Deadline: This application must be
CUSTODY OF A COMPLETED VOTER REGISTRATION FORM
residence with this application or anytime up until election
postmarked or hand delivered to your county voter
(not a receipt from the county for voter registration purposes)
day. Proof of residence can be met by submitting either:
registration office no later than 29 days before the next
(1) a COPY of your current and valid photo identification or
election. If you miss this deadline, your application will be
NOTE: If you accept a completed form from another person, in order
(2) a current utility bill, bank statement, government check,
processed when registration reopens.
to submit his or her registration for consideration, you must submit
paycheck, or government document that shows your name
Box 15: If you or the Indiana Election Division do not file
the completed form to the county voter registration office or Indiana
and address at the address you provided on this
this application with the county voter registration office,
Election Division by noon 10 days after receipt or the registration
application. Please do not send originals. Cover any
the person who accepts custody of the application (with
deadline, whichever occurs first.
account information with a permanent marker.
the exception of a member of the same household) must
FILL IN ALL APPLICABLE BOXES IN BLUE OR BLACK INK.
complete this certification before filing the application with
I accepted custody of this completed application on ___/____/20___.
DO NOT FAX OR EMAIL FORM AFTER COMPLETING IT.
the county voter registration office or the Indiana Election
Mail or hand deliver the completed application to:
Division by noon 10 days after receipt or the registration
____________________County Voter Registration Office
deadline, whichever occurs first.
_______________________________________________________
______________________________________________
Printed Name
_______________________________, IN ___________
_______________________________________________________
Residence Address
Please detach and give the receipt above to the applicant if you are accepting custody of a completed application.
New registration
Indiana county where you live:
Date processed
Township / precinct
County tracking number
COUNTY USE
Check boxes
1
2
Address change (See Box 6)
that apply:
ONLY
Name change (See Box 13)
Gender
Last Name
First Name
Middle Name or Initial
Suffix
3
Female
Jr. Sr. II III IV
Male
Residence Address (No Post Office Boxes) if no address, write short description or attach map.
Apartment Number
City / Town
State
ZIP Code
4
IN
Mailing Address, if different from Box 4, if same, print “SAME”
Apartment Number
City / Town
State
ZIP Code
5
Previous Voter Registration Address
County
Apartment Number
City / Town
State
ZIP Code
6
Date of Birth (mm/dd/yy)
Telephone number (Optional)
E-mail (Optional)
7
8
9
Are you a citizen of the
Will you be at least 18 years of age
Establish a Voter Identification Number—Applicant must provide a number or indicate “None”.
United States of America?
on or before election day?
Indiana Driver’s License Number or Bureau of Motor Vehicles ID Card Number
Provide your 10-digit Indiana issued driver’s
license number. If you do not possess an
Last 4 Digits of Social Security Number
10
11
12
Yes
No
Yes
No
Indiana driver’s license, then provide the last 4
None
digits of your social security number here. If you
have none of these, check “None”.
If you changed your name, what was your
Last Name
First Name
Middle Name or Initial
Suffix
13
name before you changed it? If you have not
Jr. Sr. II III IV
changed your name, skip this question.
I authorize my voter registration at any other address to be cancelled. I swear or affirm that:
CERTIFIED STATEMENT OF ACCEPTANCE
To be completed by a person who accepts custody of the completed application
I am a citizen of the United States.
before filing with a county voter registration office or the Indiana Election
I will be at least 18 years of age at the next general or municipal election.
Division. Does not apply to a person accepting a form from member of
I will have lived in my precinct for at least 30 days before the next election.
household.
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 affirm under the penalties for perjury that I accepted custody of this completed
I understand that if I sign this statement knowing that it is not true I am committing perjury and can be fined
application from the applicant on (insert date): ____/_____/20___.
up to $10,000, jailed for up to three years or both.
14
15
Signature of Applicant
Date (mm/dd/yy)
____________________________________________________________________
Printed Name
If applicant is unable to sign the application due to a disability, the person who wrote the applicant’s name on the line
____________________________________________________________________
above at the applicant’s request, must provide his/her name and address below.
Residence Address
Name
Address
Telephone number (Optional)
____________________________________________________________________
Signature
If you accept a completed form from another person, you must submit it to the county voter registration office or the Indiana Election Division by noon 10 days after receipt or the registration deadline, whichever occurs first
46965
Reset Form
INDIANA COUNTY VOTER REGISTRATION
(VRG-11)
APPLICATION
For election info, see:
www.indianavoters.com
State Form 46965 (R12 / 9-13)
Indiana Election Commission
Acknowledgment Notice: You will be sent a notice from
You can use this application to: Apply to register to vote
Box 4: Residence Address Print the address where you
your county voter registration office acknowledging receipt
in Indiana or change your name and address on your
live. If your address is a rural route, include the box number.
of your application. The notice informs you whether your
record or transfer your registration if you move out of your
If your residence has no address or street number, write a
application was approved by the county voter registration
precinct.
short description of its location in Box 4 or attach a map.
office. If your application is incomplete, you will be asked
To register you must: Be a citizen of the United States; be
Boxes 10 or 11: If you check “no” in response to either
to provide additional information. If you do not receive a
at least 18 years old on the day of the next general or
question in Boxes 10 or 11, do not complete this
notice within 30 days of filing this application, contact your
municipal election; have lived in your precinct for at least
application.
county voter registration office.
30 days before the next election; and not currently be
Box 12: Voter Identification Number: You are required
imprisoned after being convicted of a crime.
to provide your Indiana driver’s license number as issued
Indiana Election Division
If you are registering to vote in Indiana for the first time, and
by the Indiana Bureau of Motor Vehicles. If you do not
302 West Washington Street, Room E204
send this application by mail, you must provide additional
have an Indiana driver’s license, provide the last four
Indianapolis, IN 46204-2743
residence documentation before voting. If the county is
digits of your social security number. If you do not have
Telephone: (317) 232-3939
able to match your driver’s license number or social security
an Indiana driver’s license number, or a social security
Toll-free (Indiana only): (800) 622-4941
number with an existing Indiana identification record
number, you must indicate “None”.
www.in.gov/sos/elections
bearing the same number, name and date of birth you
Box 14: This application cannot be processed without
provide on the application, you have met the requirement.
the voter’s original signature in this section.
APPLICANT’S RECEIPT FROM INDIVIDUAL ACCEPTING
You can also meet this requirement by submitting proof of
Registration Deadline: This application must be
CUSTODY OF A COMPLETED VOTER REGISTRATION FORM
residence with this application or anytime up until election
postmarked or hand delivered to your county voter
(not a receipt from the county for voter registration purposes)
day. Proof of residence can be met by submitting either:
registration office no later than 29 days before the next
(1) a COPY of your current and valid photo identification or
election. If you miss this deadline, your application will be
NOTE: If you accept a completed form from another person, in order
(2) a current utility bill, bank statement, government check,
processed when registration reopens.
to submit his or her registration for consideration, you must submit
paycheck, or government document that shows your name
Box 15: If you or the Indiana Election Division do not file
the completed form to the county voter registration office or Indiana
and address at the address you provided on this
this application with the county voter registration office,
Election Division by noon 10 days after receipt or the registration
application. Please do not send originals. Cover any
the person who accepts custody of the application (with
deadline, whichever occurs first.
account information with a permanent marker.
the exception of a member of the same household) must
FILL IN ALL APPLICABLE BOXES IN BLUE OR BLACK INK.
complete this certification before filing the application with
I accepted custody of this completed application on ___/____/20___.
DO NOT FAX OR EMAIL FORM AFTER COMPLETING IT.
the county voter registration office or the Indiana Election
Mail or hand deliver the completed application to:
Division by noon 10 days after receipt or the registration
____________________County Voter Registration Office
deadline, whichever occurs first.
_______________________________________________________
______________________________________________
Printed Name
_______________________________, IN ___________
_______________________________________________________
Residence Address
Please detach and give the receipt above to the applicant if you are accepting custody of a completed application.
New registration
Indiana county where you live:
Date processed
Township / precinct
County tracking number
COUNTY USE
Check boxes
1
2
Address change (See Box 6)
that apply:
ONLY
Name change (See Box 13)
Gender
Last Name
First Name
Middle Name or Initial
Suffix
3
Female
Jr. Sr. II III IV
Male
Residence Address (No Post Office Boxes) if no address, write short description or attach map.
Apartment Number
City / Town
State
ZIP Code
4
IN
Mailing Address, if different from Box 4, if same, print “SAME”
Apartment Number
City / Town
State
ZIP Code
5
Previous Voter Registration Address
County
Apartment Number
City / Town
State
ZIP Code
6
Date of Birth (mm/dd/yy)
Telephone number (Optional)
E-mail (Optional)
7
8
9
Are you a citizen of the
Will you be at least 18 years of age
Establish a Voter Identification Number—Applicant must provide a number or indicate “None”.
United States of America?
on or before election day?
Indiana Driver’s License Number or Bureau of Motor Vehicles ID Card Number
Provide your 10-digit Indiana issued driver’s
license number. If you do not possess an
Last 4 Digits of Social Security Number
10
11
12
Yes
No
Yes
No
Indiana driver’s license, then provide the last 4
None
digits of your social security number here. If you
have none of these, check “None”.
If you changed your name, what was your
Last Name
First Name
Middle Name or Initial
Suffix
13
name before you changed it? If you have not
Jr. Sr. II III IV
changed your name, skip this question.
I authorize my voter registration at any other address to be cancelled. I swear or affirm that:
CERTIFIED STATEMENT OF ACCEPTANCE
To be completed by a person who accepts custody of the completed application
I am a citizen of the United States.
before filing with a county voter registration office or the Indiana Election
I will be at least 18 years of age at the next general or municipal election.
Division. Does not apply to a person accepting a form from member of
I will have lived in my precinct for at least 30 days before the next election.
household.
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 affirm under the penalties for perjury that I accepted custody of this completed
I understand that if I sign this statement knowing that it is not true I am committing perjury and can be fined
application from the applicant on (insert date): ____/_____/20___.
up to $10,000, jailed for up to three years or both.
14
15
Signature of Applicant
Date (mm/dd/yy)
____________________________________________________________________
Printed Name
If applicant is unable to sign the application due to a disability, the person who wrote the applicant’s name on the line
____________________________________________________________________
above at the applicant’s request, must provide his/her name and address below.
Residence Address
Name
Address
Telephone number (Optional)
____________________________________________________________________
Signature
If you accept a completed form from another person, you must submit it to the county voter registration office or the Indiana Election Division by noon 10 days after receipt or the registration deadline, whichever occurs first
46965