Indiana Voter Registration Form

In the case of wanting to register as a voter in the State of Indiana, the following form has to be completed and submitted.

Extracted Text for Proper Search

If Not Typed, 	Please Print in Blue or Black Ink	 	
INDIANA VOTER REGISTRATION APPLICATION	                       	(VRG-7)	 	State Form 50504 (R5/12-05) 
Indiana Election Commission  	You can use this application to: 
 Apply to register to vote in Indiana or 
 Change your name and address on your voter registra tion record. 
To register you must: 
  Be a citizen of the United States; 
 Be at least 18 years old on the day of the next gen eral or municipal election; 
 Have lived in your precinct for at least 30 days be fore the next election (except for 
certain military voters) ; and  
 Not currently be imprisoned after being convicted o f a crime. 
If you move: 
  You must transfer your registration whenever you mo ve out of your precinct.  
 You may use this application to transfer your regis tration. You may mail or hand deliver 
the completed application to your county registrati on office. 
To complete this form:  
FILL IN ALL THE BOXES THAT APPLY TO YOU IN BLUE OR  BLACK INK 
Box 4: Residence Address  Type or print the address where you live (number, s treet, 
apartment number, city/town, and ZIP code). If your  address is a rural route or star route, 
be sure to include the box number. If this address  does not have a street number, draw a 
map in Box 15.  
Box 5: Mailing Address  If this address is the same as Box 4, just print “ SAME” in this box. 
Box 6: Previous Voter Registration Address  If you have been registered previously, 
please list your most recent registration address. 
Boxes 8 and 9:   These questions are optional. Your application wi ll be processed even if 
you do not answer these questions.  
Box 10: Identification Documentation  If you are registering to vote in Indiana for the  first 
time, and you are sending this application by mail,  you must provide identification 
documentation. Identification may include a current  and valid photo id, current utility bill, 
bank statement, government check, paycheck, or gove rnment document that shows the 
name and address of the voter. You may include a co py of your identification with this 
application. Do not mail an ORIGINAL copy of your d ocument! If you do not provide 
identification with this application or to the coun ty voter registration office before election 
day, you will be asked for it the first time you vo te.  
Box 11: If you check “no” in response to the question in Bo x 11, you may not complete this 
application.    
Box 12:  The question in Box 12 requires a person to be at l east 18 years of age by the 
next general or municipal election. If you check “n o” in response to the question in Box 12, 
you may not complete this application.   Box 13:
 Voter Identification Number  In Box 13, you are required to provide your Indian a 
driver’s license number as issued by the Indiana Bu reau of Motor Vehicles. If you do not 
have an Indiana driver’s license,  provide the last four digits of your social securi ty number. 
If you do not have an Indiana driver’s license numb er, or a social security number, a voter 
identification number will be assigned to you.   
Box 14:   If this is an application for a name change, prov ide your previous name in Box 14. 
If you have not changed your name, skip this questi on. 
Box 15:   Skip this question if the address where you live  has a street name and number 
(such as 100 Maple Street). If you have a rural rou te or star route address, please draw a 
simple map that shows the nearest crossroads or str eet intersection and where your 
residence is located. If you do not live in a house  or other building, please draw a map that 
shows where you usually sleep and the nearby street s. 
Box 16:  This application cannot be processed without the vo ter’s original signature	 
in this section.  DO NOT FAX THIS FORM AFTER COMPLE TING IT. 
Registration Deadlines:  In order to be processed for the next election, thi s application 
must be postmarked or hand delivered to your county  voter registration office no later than 
29 days before the next election. If your county re gistration office receives this application 
after that day, you will be unable to vote in the n ext election. If you miss this deadline, your 
registration application will be processed when reg istration reopens. Some military voters 
and their family members can register until noon on  election day. Contact your county voter 
registration office for information if you may qual ify to do so.  
Acknowledgment Notice:  You will be sent a notice from your county voter re gistration 
office that acknowledges receipt of your voter regi stration application. The notice informs 
you whether your registration application was appro ved by the county voter registration 
office. The notice may identify where you can vote.   If your registration application is 
incomplete, you may be contacted and asked to provi de additional information. If you have 
not received an acknowledgment notice within 30 day s of filing this application you should 
contact your county voter registration office.  
Questions?  Call your county voter registration office or the I ndiana Election Division for 
assistance.  
 	
Indiana Election Division 302 West Washington Street, Room E204  
Indianapolis, Indiana 46204-2743  
Telephone:  317-232-3939 or Toll-free Indiana only:   800-622-4941  
www.in.gov/sos/elections	
 
[email protected]   	
 	
1 	Check boxes  
that apply: 	New registration Address change  (See Box 6) Name change  (See Box 14) 	2 	Indiana county where you live: 
         	 	COUNTY USE ONLY 	
Date processed 	Township/Precinct 	County Tracking Number 	
3 	Gender  Female          Male	 	
Last Name 
         	  	
First Name 
           	
Middle Name or Initial 
           	
Suffix Jr.  Sr.  II  III  IV  	
4 	Residence Address (No Post Office Boxes) 
           	
Apt. No. 
           	
City / Town 
         	  State 	IN 	
Zip Code 
           	
5 	Mailing Address, if different from Box 4, 
if same, print “SAME” 
           	
Apt. No. 
           	
City / Town 
         	 State 	           	
Zip Code 
           	
6 	Previous Voter Registration Address 
         	  County	
 	Apt. No. 
           	
City / Town 
         	 State 	           	
Zip Code 
           	
7 	Date of Birth 
(mm/dd/yy) 
           	8 	Telephone number  (If available) 
         	 	9 	E-mail (If available) 
           	10 	Are you including identification documentation? 
(See instructions for Box 10 above.) 	
 Yes         	 No  	Voter Identification Number 	
11 	
Are you a citizen of the United States 
of America? 	
 Yes   	 No 	
12 	
 Will you be at least 18 years of age on or before election day? 	
 Yes   	 No 	
13 	Provide  your  10-digit	  Indiana  issued  driver’s 
license  number.  If  you  do  not  possess  an  
Indiana driver’s license, then provide the last 	
4 digits	 of your social security number here. 	
  Driver’s License Number  Social Security Number  None	   	
14 
If you have changed your name, what was your name  
before you changed it? 
If you have not changed 
your name, skip this question.  	Last Name 
         	  	
First Name 
           	
Middle Name or Initial 
           	
Suffix Jr.  Sr.  II  III  IV  	I authorize my voter registration at any other address to be c ancelled. I swear or affirm that: 
   I am a citizen of the United States.	 	  I will be at least 18 years of age at the next genera l or municipal election.	 	  I will have lived in my precinct for at least 30 days  before the next election.	 	  I am not currently in prison after being convicted of a crim e.	 	  All the above information and all other statements on this form  are true.	 	  I understand that if I sign this statement knowing that it is  not true I am committing perjury and 
can be fined up to $10,000, jailed for up to three year s or both.	 	
Signature of Applicant  Date 
If applicant is unable to fill out the application due to disability, the person who helped the applic ant with this 
application lists their name, address and telephone  number in the box below. (Telephone number is opti onal.) 	
15 	
Map/Diagram: If your residence has no address, street number or name (such 
as 100 Maple Street), please draw a map showing whe re your residence is 
located, include roads and landmarks.  Otherwise, skip this question. 
                                                    N 
      
                  
W                                                                       E 
     
                                                      
                                                    S 	
 16 	
Name  Address  City/Town 	Telephone Number (optional)	 	 	                                                                                  50504

Indiana County Voter Registration Offices 
Sign and Mail this Completed Voter Registration App lication to the county where you live or to the Indiana Election Division	
 	ADAMS  
Adams Co. Circuit Court Clerk  
112 S. Second 
P.O. Box 189 
Decatur, IN  46733 – 0189 
(260) 724-5300 ext. 2110   
ALLEN  
Allen Co. Board of Voter Registration  
City County Building 
1 East Main Street, Room 132 
Fort Wayne, IN  46802 - 1809  
(260) 449-7154    
BARTHOLOMEW  
Bartholomew Co. Circuit Court Clerk  
P.O. Box 924 
Columbus, IN  47202 - 0924  
(812) 379-1604   
BENTON  
Benton Co. Circuit Court Clerk  
706 E. 5	
th Street 
Suite 37 
Fowler, IN  47944 - 1556 
(765) 884-0930    
BLACKFORD  
Blackford Co. Circuit Court Clerk  
110 W. Washington St. 
Hartford City, IN  47348 - 2298 
(765) 348-7217    
BOONE  
Boone Co. Circuit Court Clerk  
Room 212, Courthouse Square  
Lebanon, IN  46052 - 2100 
(765) 483-5251   
BROWN  
Brown Co. Circuit Court Clerk  
P.O. Box 85 
Nashville, IN  47448 - 0085 
(812) 988-5511    
CARROLL 
Carroll Co. Circuit Court Clerk 
101 W. Main St. 
Delphi, IN 46923 
(765) 564-6795    
CASS  
Cass Co. Circuit Court Clerk  
200 Court Park, Room 103 
Logansport, IN  46947 - 3192 
(574) 753-7870    
CLARK 
Clark Co. Circuit Court Clerk 
501 E. Court Avenue 
Jeffersonville, IN  47130-4090  
(812) 285-6329    
CLAY  
Clay Co. Circuit Court Clerk  
P.O. Box 33 
609 E. National Ave. 
Brazil, IN  47834 - 0033 
(812) 448-9023   
CLINTON  
Clinton Co. Circuit Court Clerk  
265 Courthouse Square 
Frankfort, IN  46041 - 1993 
(765) 659-6337    
CRAWFORD  
Crawford Co. Circuit Court Clerk  
P.O. Box 375 
Court St. 
English, IN 47118 - 0375  
(812) 338-2565   
DAVIESS  
Daviess Co. Circuit Court Clerk  
200 E. W alnut Street 
P.O. Box 739 
Washington, IN  47501 - 0739 
(812) 254-8679    
DEARBORN  
Dearborn Co. Circuit Court Clerk  
215 W. High Street  
Lawrenceburg, IN  47025 - 1909 
(812) 537-8869    
DECATUR  
Decatur Co. Circuit Court Clerk  
150 Courthouse Square 
Suite 244 
Greensburg, IN  47240 - 2080 
(812) 663-8223   
DEKALB  
Dekalb Co. Circuit Court Clerk  
P.O. Box 230 
100 S. Main Street 
Auburn, IN  46706 - 0230 
(260) 925-9787    
DELAWARE  
Delaware Co. Board of Voter Registration  
100 W est Main Street, Room 200 
Muncie, IN  47305 - 2836 
(765) 747- 7812      DUBOIS 
Dubois Co. Circuit Court Clerk  
One Courthouse Square, Room 104 
Jasper, IN  47546 -3058  
(812) 481-7035   
ELKHART  
Elkhart Co. Board of Voter Registration  
County Office Bldg.  Rm. L4 
117 North 2	
nd Street 
Goshen, IN  46526 - 3243 
(574) 535-6774   
FAYETTE  
Fayette Co. Circuit Court Clerk  
P.O. Box 607 
Connersville, IN  47331 - 0607 
(765) 825-1813    
FLOYD  
Floyd Co. Circuit Court Clerk  
311 W. 1
st St. Rm. 235 
P.O. Box 1056  
New Albany, IN  47150  
(812) 948-5419    
FOUNTAIN  
Fountain Co. Circuit Court Clerk  
P.O. Box 183 
Covington, IN  47932  
(765) 793-2192   
FRANKLIN  
Franklin Co. Circuit Court Clerk  
459 Main Street  
Brookville, IN  47012 - 1486  
(765) 647-5111    
FULTON  
Fulton Co. Circuit Court Clerk  
815 Main Street 
Rochester, IN  46975 - 0524 
(574) 223-7713    
GIBSON  
Gibson Co. Circuit Court Clerk  
P.O. Box 630  
Princeton, IN  47670 - 0630 
(812) 385-2541     
GRANT  
Grant Co. Board of Voter Registration  
Courthouse, Suite B-9 
101 E. 4
th Street 
Marion, IN  46952 - 4055 
(765) 664-9880    
GREENE 
Greene Co. Circuit Court Clerk 
P.O. Box 229 
Bloomfield, IN  47424 - 0229 
(812) 384-2015    
HAMILTON  
Hamilton Co. Board of Voter Registration  
1 Hamilton County Square 
Suite 13 
Noblesville, IN  46060 - 2230 
(317) 776-9632    
HANCOCK  
Hancock Co. Board of Voter Registration  
9 East Main Street 
Room 202 
Greenfield, IN  46140 - 2320 
(317) 462-1171    
HARRISON  
Harrison Co. Circuit Court Clerk  
Courthouse, Room 203 
300 North Capitol Avenue  
Corydon, IN  47112 - 1155  
(812) 738-8790    
HENDRICKS  
Hendricks Co. Circuit Court Clerk  
P.O. Box 599 
Danville, IN  46122 - 0599 
(317) 745-9313    
HENRY  
Henry Co. Board of Voter Registration  
P.O. Box B  
New Castle, IN  47362 - 1044 
(765) 529-3000   
HOWARD  
Howard Co. Board of Voter Registration  
104 North Buckeye Street, Room 106 
Kokomo, IN  46901 - 9004 
(765) 456-2219    
HUNTINGTON 
Huntington Co. Circuit Court Clerk 
P.O. Box 228 
201 North Jefferson Street 
Huntington, IN  46750  
(260) 358-4820    
JACKSON  
Jackson Co. Circuit Court Clerk  
111 South Main Street 
P.O. Box 122 
Brownstown, IN  47220 -0122 
(812) 358-6120    
JASPER  
Jasper Co. Circuit Court Clerk  
115 W est Washington 
Rensselaer, IN  47978  
(219) 866-4929   JAY  
Jay Co. Circuit Court Clerk  
120 North Court 
Portland, IN  47371 – 2195  
(260) 726-4951   
JEFFERSON  
Jefferson Co. Circuit Court Clerk  
Courthouse, Room 203 
300 East Main Street 
Madison, IN  47250 - 3594 
(812) 265-8926    
JENNINGS  
Jennings Co. Circuit Court Clerk  
P.O. Box 385 
Vernon, IN  47282 - 0385 
(812) 352-3080   
JOHNSON  
Johnson Co. Board of Voter Registration  
P.O. Box 451 
Franklin, IN  46131 - 0451  
(317) 346-4466    
KNOX  
Knox Co. Circuit Court Clerk  
101 North 7	
th Street 
Vincennes, IN  47591 - 2022 
(812) 895-4928    
KOSCIUSKO  
Kosciusko Co. Circuit Court Clerk  
121 North Lake Street 
Warsaw, IN  46580 - 2788  
(574) 372-2332   
LAGRANGE  
LaGrange Co. Circuit Court Clerk  
105 North Detroit Street 
LaGrange, IN  46761 - 1801 
(260) 449-6358   
LAKE  
Lake Co. Board of Voter Registration  
2293 North Main Street, Suite 16  
Crown Point, IN  46307  
(219) 755-3795   
LAPORTE  
LaPorte Co. Board of Voter Registration  
813 Lincolnway, Suite 103 
LaPorte, IN  46350 - 3401 
(219) 326-6808 ext. 250   
LAWRENCE  
Lawrence Co. Circuit Court Clerk  
916 15	
th St. Room 31 
Bedford, IN  47421 - 3800 
(812) 277-2036   
MADISON  
Madison Co. Board of Voter Registration  
16 East 9
th Street, Suite 208 
Anderson, IN  46016 - 1588 
(765) 641-9657    
MARION  
Marion Co. Board of Voter Registration  
200 East W ashington, W131  
Indianapolis, IN  46204 - 3355 
(317) 327-5040    
MARSHALL  
Marshall Co. Circuit Court Clerk  
211 W est Madison Street 
Plymouth, IN  46563 - 1762 
(574) 935-8713    
MARTIN  
Martin Co. Circuit Court Clerk  
111 Main St.   
P.O. Box 120 
Shoals, IN  47581 
(812) 247-3651   
MIAMI  
Miami Co. Circuit Court Clerk  
P.O. Box 184 
Peru, IN  46970 - 0184 
(765) 472-3901 ext. 226   
MONROE  
Monroe Co. Board of Voter Registration  
301 North College Avenue, Room 202 
Bloomington, IN  47401 - 3865 
(812) 349-2690    
MONTGOMERY  
Montgomery Co. Circuit Court Clerk  
100 East Main Street, Room 203 
P.O. Box 768 
Crawfordsville, IN  47933 - 0768  
(765) 364-6437   
MORGAN  
Morgan Co. Circuit Court Clerk  
P.O. Box 1556 
Martinsville, IN  46151 - 1556 
(765) 342-1029   
NEWTON  
Newton Co. Circuit Court Clerk  
P.O. Box 49 
Kentland, IN  47951 - 0049  
(219) 474-6081   NOBLE  
Noble Co. Circuit Court Clerk  
101 North Orange Street 
Albion, IN  46701 – 1092  
(260) 636-2736   
OHIO  
Ohio Co. Circuit Court Clerk  
P.O. Box 185 
Rising Sun, IN  47040 - 0185 
(812) 438-2610   
ORANGE  
Orange Co. Circuit Court Clerk  
1 Court Street  
Orange County Courthouse 
Paoli, IN  47454 - 9632 
(812) 723-2649    
OWEN  
Owen Co. Circuit Court Clerk  
P.O. Box 146 
Spencer, IN  47460 - 0146  
(812) 829-5028   
PARKE  
Parke Co. Circuit Court Clerk  
116 W est High Street 
Room 204 
Rockville, IN  47872 - 1781 
(765) 569-5132   
PERRY  
Perry Co. Circuit Court Clerk  
2219 Payne Street  
Tell City, IN  47586 - 2832  
(812) 547-3741    
PIKE  
Pike Co. Circuit Court Clerk  
801 Main St. 2	
nd Floor 
Petersburg, IN  47567 - 1298 
(812) 354-6025    
PORTER  
Porter Co. Board of Voter Registration  
Administration Center   
Suite 105 
155 Indiana Avenue 
Valparaiso, IN  46383 - 5555 
(219) 465-3484    
POSEY  
Posey Co. Circuit Court Clerk  
P.O. Box 606 
Mt. Vernon, IN  47620 - 0606 
(812) 838-1339   
PULASKI  
Pulaski Co. Circuit Court Clerk  
112 East Main 
Room 230 
Winamac, IN  46966 - 1394 
(574) 946-6461   
PUTNAM  
Putnam Co. Circuit Court Clerk  
P.O. Box 546 
Greencastle, IN  46135 - 0546  
(765) 655-1538   
RANDOLPH  
Randolph Co. Circuit Court Clerk  
P.O. Box 230 
Winchester, IN  47394 - 0230 
(765) 584-4717    
RIPLEY  
Ripley Co. Circuit Court Clerk  
P.O. Box 177 
115 N. Main Street  
Versailles, IN  47042   
(812) 689-4783   
RUSH  
Rush Co. Circuit Court Clerk  
101 East 2	
nd Street 
P.O. Box 429 
Rushville, IN  46173 - 0429 
(765) 932-4522   
ST. JOSEPH  
St. Joseph Co. Board of Voter Registration 
City-County Building, 4	
th Floor 
227 W est Jefferson Boulevard 
South Bend, IN  46601 - 1871 
(574) 235-9520   
SCOTT  
Scott Co. Circuit Court Clerk  
1 East McClain Avenue 
Scottsburg, IN  47170 - 1885 
(812) 752-8420    
SHELBY  
Shelby Co. Circuit Court Clerk  
P.O. Box 198 
Shelbyville, IN  46176 - 0198 
(317) 392-6324    
SPENCER  
Spencer Co. Circuit Court Clerk  
P.O. Box 12 
200 Main Street 
Rockport, IN  47635 - 0012  
(812) 649-6017     STARKE  
Starke Co. Circuit Court Clerk  
Courthouse, Room E 
53 East Washington Street 
Knox, IN  46534 - 1197 
(574) 772-9160   
STEUBEN  
Steuben Co. Circuit Court Clerk  
55 South Public Square 
Angola, IN  46703 – 1945  
(260) 668-1000 ext. 2220   
SULLIVAN  
Sullivan Co. Circuit Court Clerk  
Courthouse, Room 370 
100 Courthouse Square 
Sullivan, IN  47882 - 0370 
(812) 268-4657    
SWITZERLAND  
Switzerland Co. Circuit Court Clerk  
Courthouse  
212 W est Main  
Vevay, IN  47043 - 1180 
(812) 427-3175   
TIPPECANOE  
Tippecanoe Co. Board of Voter  
Registration 
301 Main Street 
Lafayette, IN  47901 - 1360 
(765) 423-9316    
TIPTON 
Tipton Co. Circuit Court Clerk 
101 East Jefferson 
Tipton, IN  46072 - 1901 
(765) 675-2795   
UNION  
Union Co. Circuit Court Clerk  
26 West Union Street 
Liberty, IN  47353 - 1396 
(765) 458-6121   
VANDERBURGH  
Vanderburgh Co. Voter Registration  
Civic Center Complex, Room 106 
1 NW Martin Luther King Jr. Boulevard 
Evansville, IN  47708 - 1828 
(812) 435-5224   
VERMILLION  
Vermillion Co. Circuit Court Clerk  
P.O. Box 10 
Newport, IN  47966 - 0008 
(765) 492-3500    
VIGO  
Vigo Co. Board of Voter Registration  
Courthouse, Room 3 
33 South 3	
rd Street 
Terre Haute, IN  47808 - 3472 
(812) 462-3393   
WABASH  
Wabash Co. Circuit Court Clerk  
One West Hill Street, Suite 6  
Wabash, IN  46992 - 3175  
(260) 563-0661 ext. 58   
WARREN  
Warren Co. Circuit Court Clerk  
125 North Monroe Street 
Suite 11 
Williamsport, IN  47993 - 1198 
(765) 762-2834   
WARRICK  
Warrick Co. Circuit Court Clerk  
1 County Square  
Suite 220 
Boonville, IN  47601 - 1594 
(812) 897-6161   
WASHINGTON  
Washington Co. Circuit Court Clerk  
99 Public Square North 
Salem, IN  47167 - 2098 
(812) 883-5748   
WAYNE  
Wayne Co. Circuit Court Clerk  
301 E. Main Street 
Richmond, IN  47374 
(765) 973-9304   
WELLS  
Wells Co. Circuit Court Clerk  
102 W est Market Street 
Suite 201 
Bluffton, IN  46714 - 2091  
(260) 824-6480    
WHITE  
White Co. Circuit Court Clerk  
P.O. Box 350 
Monticello, IN  47960 - 0350 
(574) 583-1531   
WHITLEY  
Whitley Co. Circuit Court Clerk  
101 W est Van Buren Street 
Columbia City, IN  46725 - 2087  
(260) 248-3164