Fillable Form Sbe R-19 - Illinois Voter Registration Application printable pdf download

ILLINOIS VOTER REGISTRATION APPLICATION

Suggested January 2014

FOR ILLINOIS RESIDENTS ONLY

TO COMPLETE THIS FORM:

SBE R-19

•

Box 1-If you do not have a middle name, leave blank.

TO VOTE YOU MUST:

•

Box 3-If mailing address is same as Box 2, write “same”.

•

Be a United States citizen

•

Box 4-If you have never registered before, leave blank. If you

Be at least 18 years old (some 17 year olds may vote in the

do not remember your former address; provide as much

General Primary)

information as possible.

•

Live in your election precinct at least 30 days

•

Box 5-If you have not changed your name, leave blank.

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Not be convicted and in jail

•

Box 9-If you have an Illinois Driver’s License or Secretary of State

•

Not claim the right to vote anywhere else

ID, check the first box and fill in the number. If you do not have a

TO VOTE IN THE NEXT ELECTION:

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

Mail or deliver this application to your County Clerk or Board

a SSN, check the third box and send a copy of the appropriate

of Election Commissioners no later than 28 days before the

next election.

(click here for County Clerk/Election Board

document (as described in the “Important Information” section)

along with this form.

listings)

or go to

•

10-Read, date and personally sign your name or make your

IMPORTANT INFORMATION:

mark in the box.

•

If you do not have a driver’s license, State Identification Card or

social security number, and this form is submitted by mail, and

IF YOU HAVE NO STREET ADDRESS,

you have never registered to vote in the jurisdiction you are now

below describe your home: list the name of subdivision; cross

registering in, then you must send, with this application, either (i)

streets; roads; landmarks; mileage and/or neighbors’ names.

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

If you have questions about completing this form, please call

delivering this application, call your County Clerk or Board of

the State Board of Elections at (217)782-4141 or (312)814-6440

Election Commissioners.

(or webmaster@elections.il.gov).

TYPE OR PRINT CLEARLY IN BLACK OR BLUE INK

Are you a citizen of the United States of America?

(check one) yes

Office Use

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

change your address

change your name

Last Name

First Name

Middle Name or Initial

Suffix (Circle One)

Jr. Sr. II III IV

Address where you live (House No., Street Name, Apt. No.)

City/Village/Town

Zip Code

County

Township

Mailing address (P.O. Box)

City/Village/Town, State

Zip Code

Email (optional)

Former Registration Address: (include City and State and Zip Code)

Former County

5. Former Name: (if changed)

Date of Birth: MM/DD/YY

Home telephone number

9. ID number – check the applicable box and provide the appropriate number

including area code (optional)

IL Driver’s License or, if none, Sec. of State ID or

Last 4 digits of Social Security Number

Sex (circle one)

(

)

I have none of the above-listed identification numbers.

______________________________________________________________

10. Voter Affidavit – Read all statements and sign within the box to the right.

This is my signature or mark in the space below.

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.

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.

__________________________________________________________________________________________________________________________________

Form Sbe R-19 - Illinois Voter Registration Application

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