Subject registering for voting by filing the Vermont Application for Addition to the Checklist (VT Voter Registration Form) will be assessed by the Town Clerk or the Board of Civil Authority regarding the eligibility requirements.Download
Extracted Text for Proper Search
VERMONT Application for Addition to the Checklist (VT VOTER REGISTRATION FORM ) 17 V.S.A. § 2145 (Please print clearly, use ballpoi nt pen, and bear down hard.) I, ________________________________________________ ______________ apply to have my name (Last Name) (First Name) (Middle Initial ) added to the checklist of the Town/City of ______________________________________. By checking the boxes below, I swear or affirm that these are true statements: Yes No Are you a citizen of the United States? Yes No Will you be eighteen years of age or older on o r before the day of election? Yes No Are you a resident of Vermont? If you checked "No" in response to any of the three questions above, DO NOT complete this form. You are not qualified to vote in Vermont . Contact the Office of the Secretary of State, El ections Division, for more information at (800) 439 -8683. I was born on ________________________ at _________ ________________________, ________________________ ___ (Date) (Town or City) (State) My principal dwelling is located at:_______________ ___________________________________________________ ____ (E911 street address including number or exact phys ical location, if no E911 address) Mailing Address: ___________________________________________________ ________ Tel. #: ___________________ Email:__________________________________________ (optional - for contact purposes only). By registering to vote in the above named town in V ermont, I authorize my name to be removed from the list of registered voters in any previous place where I was registered to vote. The last address I was registered to vote at: ___________________________________________________ _______. (Physical location – include number, street, town, state and zip code) I was previously registered with a different last name of: ___________________________ ____________________________. My VT Driver’s License or Personal I.D. # (PID#) issued by VT DMV is__________________. This # is REQUIRED. IF you do not have a VT Driver’s License or PID# issued by VT DMV enter the last 4 digits of your Social Security Number:________ . If you do not have a VT PID#, or SSN, please contac t the Office of the Secretary of State, Elections Division, (800)439-8683. By checking this box I swear or affirm that: I have taken the Voter's Oath I meet all of the eligibility requirements to vote in this municipality . I hereby swear, or affirm, under penalty of perjury and other potential federal or state criminal penal ties of up to a $10,000 fine, or imprisonment for not more than fifteen years, or both, that the statements made by me in this applic ation are true . (17 V.S.A. § 2145(f); 17 V.S.A. § 2011; 42 U.S.C. § 1973gg-10). ____________________________ ___________________ ___________________________ Today’s Date Applicant’s Signature First time Registrants in Vermont must take the voter’s oath. You must be 18 to take the oath: VOTER'S OATH (Vermont Constitution, Chapter II, Section 42): “You solemnly swear or affirm that whenever you gi ve your vote or suffrage, touching any matter that concerns the Sta te of Vermont, you will do it so as in your conscience you shall judge will most conduce to the best good of the same, as estab lished by the Constitution, without fear or favor of any person.” The person administering the oath or the applicant must sign the certification below. I hereby certify that on the___ day of ____________ ____, 20___, I administered the Voter’s Oath to the applicant, or I, the applicant, took the oath myself. Any person over 18 or the applicant can sign to attest that the oath was taken. (Check box above & sign.) Attestation:____________ __________________________ Signature of Attester ONLY if you are registering to vote for the 1 st time in Vermont, AND you are mailing this application to your town clerk individually, you must submit a photocopy of one of the followi ng: current & valid photo identification OR bank statement, utility bill, or government document with your name and current addr ess. (Do not submit I.D. if you have been previously reg istered in VT, if this form is submitted as part of a voter registration drive, or if you return this form to the clerk’s office in person.) FOR OFFICIAL USE : The Town Clerk OR the BCA has reviewed the application AND the applic ant was added to the checklist. The applicant’s usual polling place is: ___________ __________________________________. OR the applican t was rejected and NOT added to the checklist. The reason(s) for reje ction are: _____________________________________ . Signature of town clerk: ____________________________. Date Entered on Checklist: _____________ Date Noti fication Sent to Voter:_____________ Date Approved: ____________ KEEP THE PINK COPY OF THIS APPLICATION FORM . Contact your Town Clerk to make sure your application has been received. Bring pink copy to the polls when you go to vote . This is proof you have submitted an application before the deadline for registration. [SOS-VR-5/12/2014] VERMONT VOTER REGISTRATION INFORMATION (HOW TO FILL OUT THE Vermont APPLICATION FOR ADDITI ON TO THE CHECKLIST) To be eligible to vote in Vermont you must: (Eligibility requirements are in 17 V.S.A. § 2121, 2122) 1. be a citizen of the United States; 2. be a resident of Vermont and a resident of the town in which you apply to be added to the checklis t; (OR be a military or overseas voter qualified under the federal Unifo rmed and Overseas Citizens Absentee Voting Act whos e last place of residence in the United States immediately prior to moving overseas was in a Vermont town or city); 3. take, or have previously taken, the Voter's Oat h; and 4. be 18 years of age or older or will be 18 on or before the day of election. THE APPLICANT MUST REGISTER TO VOTE IN THE TOWN OR CITY WHERE HE or SHE CURRENTLY RESIDES. If you are registering to vote for the 1 st time in Vermont, and you are mailing this application to your town clerk individually, you must also submit a photocopy of o ne of the following forms of identification: current & valid photo identification or bank statement, utility bill, or government document that contains your name/c urrent address. NO photocopy of ID is required when a person registers through a state agency. You must include your Vermont DMV-issued Driver’s License Number or Personal I.D. Number (VT PID#) on the voter application . If you do not have a Driver’s License or VT PID# issued by DMV, then you must include the last four (4) digits of your Social Security Number. (SSN). If you do not have either, please contact the Off ice of the Secretary of State. Providing your e-mail address is optional, but prov ides the easiest way for the Clerk to contact you. Where to File: Keep the pink copy, and submit the top two sheets (the white and cana ry copies) of the form to the Town or City Clerk in the town or city in which you reside. Cler k addresses can be found on the Secretary of State’s web site, http:// www.sec.state.vt.us , or call your town clerk, or call the Elections Di vision at (802) 828-2363 or (800) 439-8683. YOU MUST REGISTER TO VOTE IN THE TOWN OR CITY WHERE YOU CURRENTLY RESIDE. When to File: The application must be received by 5:00 PM on the Wednesday immediately prior to the day of an election in order to vote in that election . If you apply through a state agency, your applica tion must be postmarked or accepted on or before th e Wednesday preceding the election. Getting on the Voter Checklist : You are not automatically registered to vote by filing this application. If the Town Clerk or the Board of Civil Authority finds that you meet the el igibility requirements you will be added to the checklist and become a registered voter. You will be notified in writing whether or not your application has been approved. If you hav e not received notification, call your town clerk. If you are not eligible, the Boar d must state the reason in writing and give you a c hance to be reconsidered. If you are still denied, you can appeal in writing to a su perior or district judge in your county. (No filing fee or lawyer is required.) Voter’s Oath : If you have previously voted in Vermont, do not tak e the voter’s oath again. If not, the oath can be administered by yourself , by any person over the age of 18, by the Town Cle rk, a Justice of the Peace, a Notary Public, or a Commissioned Military Officer. If you do not take oaths you may take it as an affirmation. The person who administered the oath, or you if you are attesting for yourself that you have taken the oath, must date and sign the at testation in the box. SERIOUS PENALTIES FOR FALSE INFORMATION ON AN APPLI CATION TO THE CHECKLIST It is unlawful to give false information concerning your qualifications to be a registered voter of a town or city in Vermont. The penalties are serious, including pena lties of up to a $10,000 fine or imprisonment for not more than fifteen years, or both. Note to Town and City Clerks: The applicant retains the pink copy when the applic ation is completed. After the Town Clerk or BCA takes action, complete the bottom of t he application form and mail a copy to the applicant. The laws relating to voter registration are in 17 V. S. A. §§2121-2150. If you have questions, call y our town clerk or call the Elections Division, Office of the Secretar y of State at (802) 828-2363, or (in Vermont) (800) 439-8683. Note: If you were provided this form when you applied for assistance or services from a state agency you may decline to register. If you decline to register your failure to register will remain confidential a nd will be used only for voter registration purpose s. The fact that you may have submitted this application in connection with a motor vehicle driver’s license ap plication or renewal, or through a voter registration agency will remain confidential and will be used only for voter registration purposes.