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Fold and seal, or use an envelope <br />fold in halfInstructions <br />Use this form to register to vote <br />or update your current registration. <br />Print all information clearly using <br />black or blue pen. Mail this completed <br />form to your county elections office <br />(address on back). <br />Deadline <br />This registration will be in effect for the <br />next election if postmarked no later than <br />the Monday four weeks before Election Day. <br />Voting <br />You will receive your ballot in the mail. <br />Contact your county elections office for <br />accessible voting options. <br />Public Information <br />Your name, address, gender, and date of <br />birth will be public information. <br />Notice <br />Knowingly providing false information <br />about yourself or your qualifications <br />for voter registration is a class C felony <br />punishable by imprisonment for up to <br />5 years, a fine of up to $10,000, or both. <br />Public Benefits Offices <br />If you received this form from a public <br />benefits office, where you received the <br />form will remain confidential and will be <br />used for voter registration purposes only. <br />Registering or declining to register will <br />not affect the assistance provided to <br />you by any public benefits office. If you <br />decline to register, your decision will <br />remain confidential. <br />If you believe someone interfered with <br />your right to register, or your right to <br />privacy in deciding whether to register, <br />you may file a complaint with the <br />Washington State Elections Division. <br />Contact Information <br />If you would like help with this form, contact <br />the Washington State Elections Division. <br />web www.vote.wa.gov <br />call (800) 448-4881 <br />email elections@sos.wa.gov <br />mail PO Box 40229 <br /> Olympia, WA 98504-0229 <br />last first middle suffix <br />date of birth (mm/dd/yyyy) gender <br />residential address in Washington apt # <br />city ZIP <br />mailing address, if different <br />city state and ZIP <br />phone number (optional) email address (optional) <br />1 Personal Information <br />If you answer no, do not complete this form. <br /> yes no I am a citizen of the United States of America. <br /> yes no I will be at least 18 years old by the next election. <br />2 Qualifications <br /> yes no I am currently serving in the military. <br />Includes National Guard and Reserves, <br />and spouses or dependents away from home due to service. <br /> yes no I live outside the United States. <br />3 Military / Overseas Status <br />If you do not have a Washington driver license, <br />permit, or ID, you may use the last four digits of <br />your Social Security number to register. <br />xxx-xx- <br />4 Identification — Washington Driver License, Permit, or ID <br />This information will be used to update your current registration, if applicable. <br />former last name first middle <br />former residential address city state and ZIP <br />5 Change of Name or Address <br />date <br />here <br />sign <br />here <br />I declare that the facts on this voter registration form are true. I am a citizen of the United States, I will have lived at this address in Washington for at least thirty days immediately before the next <br />election at which I vote, I will be at least 18 years old when I vote, I am not disqualified from voting <br />due to a court order, and I am not under Department of Corrections supervision for a Washington felony conviction. <br />6 Declaration <br />Washington State Voter Registration Form <br />Register online at www.myvote.wa.gov. <br /> For official use:2 / 2016N/A <br />N/A N/A <br />N/A N/A <br />N/A <br />N/A N/A <br />N/A N/A <br />0 0 0 0 0 0 0 0 0 00 0 0 <br />00 0000 0 0 <br />N/A N/A N/A <br />N/A N/A WA 98201 <br />Cassandra Jeanne <br />07/28/1971 Female