Nebraska Voter Registration Application Please Print Election Office Use Only: O853 1. Are you a citizen of the United States of America? ( ) Yes ( ) No 2. Are you at least 18 years of age, or will you be 18 years of age on or before the 1st Tuesday following the 1st Monday in November of this year? ( ) Yes ( ) No System ID Number: _________ Precinct: ____________ Split: _________ Congressional _______ Commissioner/Supervisor District:_____ Legislative _______ NRD _____ Fire ______ Other Districts ______ _______ _______ IF YOU CHECKED "NO" IN RESPONSE TO EITHER OF THE QUESTIONS ABOVE; DO NOT COMPLETE THIS FORM 3. Personal Information: Last Name First Name Nebraska Drivers Lic. # ; if none last 4 digits SS # Mid. Initial Date of Birth Suffix Maiden Name (optional) Place of Birth (optional) Phone Number (optional) ( ) work ( ) home ( ) unlisted If changing your registration in this county, is it a ( ) Party change ( If Previously Registered: Name: 4. Current Residence Address: House Number Direction Street/Road Name ) Name change ( ) Address change Address: Address example: 1612 N Michigan Avenue SW Apt. 322 Oakdale, NE 68104 Street Type Direction Unit Type Unit # City/Town State Zip Postal Address if different than residence: School Dist: County: Inside city limits ( ) Yes ( ) No, if no Section/Township/Range _____ / _____ / _____ Or directions from nearest town: 5. Party Affiliation: ( ) Democrat ( ) Republican ( ) Libertarian ( ) Nebraska ( ) Non-Partisan -no party affiliation( ) Other -if checking other, print the name of the party- __________________________________ Note: If you wish to vote in both partisan and non-partisan primary elections for state and local office, you must designate a political party on the registration form. If you check non-partisan (independent) you will receive only non-partisan ballots for state and local offices at primary elections, however, you may designate a preference at the polling place and vote in partisan primary elections for congressional offices only. Voter's Oath : To the best of my knowledge and belief, I declare under penalty of election falsification: I live in the State of Nebraska at the address provided above. I have not been convicted of a felony, or if convicted, my civil rights have been restored; and I have not been officially found to be non compos mentis (mentally incompetent). Any registrant who signs this form knowing that any of the information on the form is false shall be guilty of a Class IV felony under section 32-1502 of the Nebraska State Statutes. The penalty for such is up to 5 years imprisonment, a fine of up to $10,000.00 or both. Date ____________ Registrar __________________ 6. Voter's Signature _____________________________________________ (Full name or mark. If unable to sign, include name & address of person providing assistance) (If applicable) I. General Instructions This form may be used to: * Register to vote in Nebraska for the first time; or *Make changes to your name, address, or political party on your current Nebraska voter registration Upon completion of this form you may submit it to your local Election Office *By personal delivery *By mail or by personal messenger To be eligible to vote in an election, your completed application must be: *Delivered in person or by personal messenger prior to 6 p.m. on the second Friday preceding the election in which you wish to vote *Must be mailed and postmarked on or before the 3rd Friday preceding the election in which you wish to vote Upon receipt of this form, the County Election Office will send an acknowledgement to you indicating whether your voter registration is complete. II. Completing the Form 1. Answer questions 1 and 2, proceed to complete the form only if you answered yes to both questions. 2. If this is a change of your current county registration, note the type of change in section 3. Make your changes, sign and date. 3. If this is a new county registration, complete sections 3, 4, and 5. Failure to provide your name, date of birth, Nebraska drivers' license number, if none, the last 4 digits of your SS#, the physical location of your residence and your party affiliation will result in your voter registration being rejected or delayed. 4. Affirm the information stated by your signature and the date on this form, failure to do so will result in your registration being rejected. III. Special Instructions for Registering by Mail If you are submitting this form by mail, and you are registering in this county for the first time, you must provide a copy of: * Your current and valid photo identification, or *A copy of a current utility bill, bank statement, government check, paycheck, or other government document that shows your name and the residence address at which you are registering to vote Providing the above identification documentation along with your mail-in registration at the time you register will enable you to avoid identification requirements upon voting the first time in this county. When submitting this form by mail, (and if necessary, an envelope for the copy of valid identification) please use the appropriate address found on the back.