INDIANA VOTER REGISTRATION APPLICATION (VRG-7)

State Form 50504 (R5/12-05)

Indiana Election Commission
You can use this application to: Box 13: Voter Identification Number In Box 13, you are required to provide your Indiana
ƒ Apply to register to vote in Indiana or driver’s license number as issued by the Indiana Bureau of Motor Vehicles. If you do not
ƒ Change your name and address on your voter registration record. have an Indiana driver’s license, provide the last four digits of your social security number.
To register you must: If you do not have an Indiana driver’s license number, or a social security number, a voter
identification number will be assigned to you.
ƒ Be a citizen of the United States;
Box 14: If this is an application for a name change, provide your previous name in Box 14.
ƒ Be at least 18 years old on the day of the next general or municipal election;
If you have not changed your name, skip this question.
ƒ Have lived in your precinct for at least 30 days before the next election (except for
Box 15: Skip this question if the address where you live has a street name and number
certain military voters); and
(such as 100 Maple Street). If you have a rural route or star route address, please draw a
ƒ Not currently be imprisoned after being convicted of a crime. simple map that shows the nearest crossroads or street intersection and where your
If you move: residence is located. If you do not live in a house or other building, please draw a map that
ƒ You must transfer your registration whenever you move out of your precinct. shows where you usually sleep and the nearby streets.
ƒ You may use this application to transfer your registration. You may mail or hand deliver Box 16: This application cannot be processed without the voter’s original signature
the completed application to your county registration office. in this section. DO NOT FAX THIS FORM AFTER COMPLETING IT.
To complete this form: Registration Deadlines: In order to be processed for the next election, this application
FILL IN ALL THE BOXES THAT APPLY TO YOU IN BLUE OR BLACK INK must be postmarked or hand delivered to your county voter registration office no later than
Box 4: Residence Address Type or print the address where you live (number, street, 29 days before the next election. If your county registration office receives this application
apartment number, city/town, and ZIP code). If your address is a rural route or star route, after that day, you will be unable to vote in the next election. If you miss this deadline, your
be sure to include the box number. If this address does not have a street number, draw a registration application will be processed when registration reopens. Some military voters
map in Box 15. and their family members can register until noon on election day. Contact your county voter
Box 5: Mailing Address If this address is the same as Box 4, just print “SAME” in this box. registration office for information if you may qualify to do so.
Box 6: Previous Voter Registration Address If you have been registered previously, Acknowledgment Notice: You will be sent a notice from your county voter registration
please list your most recent registration address. office that acknowledges receipt of your voter registration application. The notice informs
you whether your registration application was approved by the county voter registration
Boxes 8 and 9: These questions are optional. Your application will be processed even if
office. The notice may identify where you can vote. If your registration application is
you do not answer these questions.
incomplete, you may be contacted and asked to provide additional information. If you have
Box 10: Identification Documentation If you are registering to vote in Indiana for the first not received an acknowledgment notice within 30 days of filing this application you should
time, and you are sending this application by mail, you must provide identification contact your county voter registration office.
documentation. Identification may include a current and valid photo id, current utility bill,
Questions? Call your county voter registration office or the Indiana Election Division for
bank statement, government check, paycheck, or government document that shows the
assistance.
name and address of the voter. You may include a copy of your identification with this
application. Do not mail an ORIGINAL copy of your document! If you do not provide
identification with this application or to the county voter registration office before election Indiana Election Division
day, you will be asked for it the first time you vote. 302 West Washington Street, Room E204
Box 11:If you check “no” in response to the question in Box 11, you may not complete this Indianapolis, Indiana 46204-2743
application. Telephone: 317-232-3939 or Toll-free Indiana only: 800-622-4941
Box 12: The question in Box 12 requires a person to be at least 18 years of age by the www.in.gov/sos/elections
next general or municipal election. If you check “no” in response to the question in Box 12, elections@iec.state.in.us
you may not complete this application.
If Not Typed, Please Print in Blue or Black Ink
New registration Indiana county where you live: Date processed Township/Precinct County Tracking Number
Check boxes COUNTY
1 that apply:
Address change (See Box 6) 2
Name change (See Box 14) USE ONLY
Gender Last Name First Name Middle Name or Initial Suffix
3 Female Jr. Sr. II III IV
Male
Residence Address (No Post Office Boxes) Apt. No. City / Town State Zip Code
4 IN
Mailing Address, if different from Box 4, if same, print “SAME” Apt. No. City / Town State Zip Code
5
Previous Voter Registration Address County Apt. No. City / Town State Zip Code
6
Date of Birth (mm/dd/yy) Telephone number (If available) E-mail (If available) Are you including identification documentation?
7 8 9 10 (See instructions for Box 10 above.)
Yes No
Voter Identification Number
Are you a citizen of the United States Will you be at least 18 years of age on
Provide your 10-digit Indiana issued driver’s Driver’s License Number
of America? or before election day?
11 12 13 license number. If you do not possess an
Indiana driver’s license, then provide the last
Social Security Number
Yes No Yes No 4 digits of your social security number here. None
If you have changed your name, what was your name Last Name First Name Middle Name or Initial Suffix
14 before you changed it? If you have not changed Jr. Sr. II III IV
your name, skip this question.
Map/Diagram: If your residence has no address, street number or name (such I authorize my voter registration at any other address to be cancelled. I swear or affirm that:
as 100 Maple Street), please draw a map showing where your residence is ƒ I am a citizen of the United States.
located, include roads and landmarks. Otherwise, skip this question. ƒ I will be at least 18 years of age at the next general or municipal election.
N ƒ I will have lived in my precinct for at least 30 days before the next election.
ƒ I am not currently in prison after being convicted of a crime.
ƒ All the above information and all other statements on this form are true.
ƒ 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 years or both.
15
16 Signature of Applicant Date
W E

If applicant is unable to fill out the application due to disability, the person who helped the applicant with this
application lists their name, address and telephone number in the box below. (Telephone number is optional.)
Name Address City/Town Telephone Number (optional)
S
50504
 Indiana County Voter Registration Offices
Sign and Mail this Completed Voter Registration Application to the county where you live or to the Indiana Election Division
ADAMS DUBOIS JAY NOBLE STARKE
Adams Co. Circuit Court Clerk Dubois Co. Circuit Court Clerk Jay Co. Circuit Court Clerk Noble Co. Circuit Court Clerk Starke Co. Circuit Court Clerk
112 S. Second One Courthouse Square, Room 104 120 North Court 101 North Orange Street Courthouse, Room E
P.O. Box 189 Jasper, IN 47546 -3058 Portland, IN 47371 – 2195 Albion, IN 46701 – 1092 53 East Washington Street
Decatur, IN 46733 – 0189 (812) 481-7035 (260) 726-4951 (260) 636-2736 Knox, IN 46534 - 1197
(260) 724-5300 ext. 2110 (574) 772-9160
ELKHART JEFFERSON OHIO
ALLEN Elkhart Co. Board of Voter Registration Jefferson Co. Circuit Court Clerk Ohio Co. Circuit Court Clerk STEUBEN
Allen Co. Board of Voter Registration County Office Bldg. Rm. L4 Courthouse, Room 203 P.O. Box 185 Steuben Co. Circuit Court Clerk
nd
City County Building 117 North 2 Street 300 East Main Street Rising Sun, IN 47040 - 0185 55 South Public Square
1 East Main Street, Room 132 Goshen, IN 46526 - 3243 Madison, IN 47250 - 3594 (812) 438-2610 Angola, IN 46703 – 1945
Fort Wayne, IN 46802 - 1809 (574) 535-6774 (812) 265-8926 (260) 668-1000 ext. 2220
(260) 449-7154 ORANGE
FAYETTE JENNINGS Orange Co. Circuit Court Clerk SULLIVAN
BARTHOLOMEW Fayette Co. Circuit Court Clerk Jennings Co. Circuit Court Clerk 1 Court Street Sullivan Co. Circuit Court Clerk
Bartholomew Co. Circuit Court Clerk P.O. Box 607 P.O. Box 385 Orange County Courthouse Courthouse, Room 370
P.O. Box 924 Connersville, IN 47331 - 0607 Vernon, IN 47282 - 0385 Paoli, IN 47454 - 9632 100 Courthouse Square
Columbus, IN 47202 - 0924 (765) 825-1813 (812) 352-3080 (812) 723-2649 Sullivan, IN 47882 - 0370
(812) 379-1604 (812) 268-4657
FLOYD JOHNSON OWEN
BENTON Floyd Co. Circuit Court Clerk Johnson Co. Board of Voter Registration Owen Co. Circuit Court Clerk SWITZERLAND
st
Benton Co. Circuit Court Clerk 311 W. 1 St. Rm. 235 P.O. Box 451 P.O. Box 146 Switzerland Co. Circuit Court Clerk
th
706 E. 5 Street P.O. Box 1056 Franklin, IN 46131 - 0451 Spencer, IN 47460 - 0146 Courthouse
Suite 37 New Albany, IN 47150 (317) 346-4466 (812) 829-5028 212 West Main
Fowler, IN 47944 - 1556 (812) 948-5419 Vevay, IN 47043 - 1180
(765) 884-0930 KNOX PARKE (812) 427-3175
FOUNTAIN Knox Co. Circuit Court Clerk Parke Co. Circuit Court Clerk
th
BLACKFORD Fountain Co. Circuit Court Clerk 101 North 7 Street 116 West High Street TIPPECANOE
Blackford Co. Circuit Court Clerk P.O. Box 183 Vincennes, IN 47591 - 2022 Room 204 Tippecanoe Co. Board of Voter
110 W. Washington St. Covington, IN 47932 (812) 895-4928 Rockville, IN 47872 - 1781 Registration
Hartford City, IN 47348 - 2298 (765) 793-2192 (765) 569-5132 301 Main Street
(765) 348-7217 KOSCIUSKO Lafayette, IN 47901 - 1360
FRANKLIN Kosciusko Co. Circuit Court Clerk PERRY (765) 423-9316
BOONE Franklin Co. Circuit Court Clerk 121 North Lake Street Perry Co. Circuit Court Clerk
Boone Co. Circuit Court Clerk 459 Main Street Warsaw, IN 46580 - 2788 2219 Payne Street TIPTON
Room 212, Courthouse Square Brookville, IN 47012 - 1486 (574) 372-2332 Tell City, IN 47586 - 2832 Tipton Co. Circuit Court Clerk
Lebanon, IN 46052 - 2100 (765) 647-5111 (812) 547-3741 101 East Jefferson
(765) 483-5251 LAGRANGE Tipton, IN 46072 - 1901
FULTON LaGrange Co. Circuit Court Clerk PIKE (765) 675-2795
BROWN Fulton Co. Circuit Court Clerk 105 North Detroit Street Pike Co. Circuit Court Clerk
nd
Brown Co. Circuit Court Clerk 815 Main Street LaGrange, IN 46761 - 1801 801 Main St. 2 Floor UNION
P.O. Box 85 Rochester, IN 46975 - 0524 (260) 449-6358 Petersburg, IN 47567 - 1298 Union Co. Circuit Court Clerk
Nashville, IN 47448 - 0085 (574) 223-7713 (812) 354-6025 26 West Union Street
(812) 988-5511 LAKE Liberty, IN 47353 - 1396
GIBSON Lake Co. Board of Voter Registration PORTER (765) 458-6121
CARROLL Gibson Co. Circuit Court Clerk 2293 North Main Street, Suite 16 Porter Co. Board of Voter Registration
Carroll Co. Circuit Court Clerk P.O. Box 630 Crown Point, IN 46307 Administration Center VANDERBURGH
101 W. Main St. Princeton, IN 47670 - 0630 (219) 755-3795 Suite 105 Vanderburgh Co. Voter Registration
Delphi, IN 46923 (812) 385-2541 155 Indiana Avenue Civic Center Complex, Room 106
(765) 564-6795 LAPORTE Valparaiso, IN 46383 - 5555 1 NW Martin Luther King Jr. Boulevard
GRANT LaPorte Co. Board of Voter Registration (219) 465-3484 Evansville, IN 47708 - 1828
CASS Grant Co. Board of Voter Registration 813 Lincolnway, Suite 103 (812) 435-5224
Cass Co. Circuit Court Clerk Courthouse, Suite B-9 LaPorte, IN 46350 - 3401 POSEY
th
200 Court Park, Room 103 101 E. 4 Street (219) 326-6808 ext. 250 Posey Co. Circuit Court Clerk VERMILLION
Logansport, IN 46947 - 3192 Marion, IN 46952 - 4055 P.O. Box 606 Vermillion Co. Circuit Court Clerk
(574) 753-7870 (765) 664-9880 LAWRENCE Mt. Vernon, IN 47620 - 0606 P.O. Box 10
Lawrence Co. Circuit Court Clerk (812) 838-1339 Newport, IN 47966 - 0008
th
CLARK GREENE 916 15 St. Room 31 (765) 492-3500
Clark Co. Circuit Court Clerk Greene Co. Circuit Court Clerk Bedford, IN 47421 - 3800 PULASKI
501 E. Court Avenue P.O. Box 229 (812) 277-2036 Pulaski Co. Circuit Court Clerk VIGO
Jeffersonville, IN 47130-4090 Bloomfield, IN 47424 - 0229 112 East Main Vigo Co. Board of Voter Registration
(812) 285-6329 (812) 384-2015 MADISON Room 230 Courthouse, Room 3
rd
Madison Co. Board of Voter Registration Winamac, IN 46966 - 1394 33 South 3 Street
th
CLAY HAMILTON 16 East 9 Street, Suite 208 (574) 946-6461 Terre Haute, IN 47808 - 3472
Clay Co. Circuit Court Clerk Hamilton Co. Board of Voter Registration Anderson, IN 46016 - 1588 (812) 462-3393
P.O. Box 33 1 Hamilton County Square (765) 641-9657 PUTNAM
609 E. National Ave. Suite 13 Putnam Co. Circuit Court Clerk WABASH
Brazil, IN 47834 - 0033 Noblesville, IN 46060 - 2230 MARION P.O. Box 546 Wabash Co. Circuit Court Clerk
(812) 448-9023 (317) 776-9632 Marion Co. Board of Voter Registration Greencastle, IN 46135 - 0546 One West Hill Street, Suite 6
200 East Washington, W131 (765) 655-1538 Wabash, IN 46992 - 3175
CLINTON HANCOCK Indianapolis, IN 46204 - 3355 (260) 563-0661 ext. 58
Clinton Co. Circuit Court Clerk Hancock Co. Board of Voter Registration (317) 327-5040 RANDOLPH
265 Courthouse Square 9 East Main Street Randolph Co. Circuit Court Clerk WARREN
Frankfort, IN 46041 - 1993 Room 202 MARSHALL P.O. Box 230 Warren Co. Circuit Court Clerk
(765) 659-6337 Greenfield, IN 46140 - 2320 Marshall Co. Circuit Court Clerk Winchester, IN 47394 - 0230 125 North Monroe Street
(317) 462-1171 211 West Madison Street (765) 584-4717 Suite 11
CRAWFORD Plymouth, IN 46563 - 1762 Williamsport, IN 47993 - 1198
Crawford Co. Circuit Court Clerk HARRISON (574) 935-8713 RIPLEY (765) 762-2834
P.O. Box 375 Harrison Co. Circuit Court Clerk Ripley Co. Circuit Court Clerk
Court St. Courthouse, Room 203 MARTIN P.O. Box 177 WARRICK
English, IN 47118 - 0375 300 North Capitol Avenue Martin Co. Circuit Court Clerk 115 N. Main Street Warrick Co. Circuit Court Clerk
(812) 338-2565 Corydon, IN 47112 - 1155 111 Main St. Versailles, IN 47042 1 County Square
(812) 738-8790 P.O. Box 120 (812) 689-4783 Suite 220
DAVIESS Shoals, IN 47581 Boonville, IN 47601 - 1594
Daviess Co. Circuit Court Clerk HENDRICKS (812) 247-3651 RUSH (812) 897-6161
200 E. Walnut Street Hendricks Co. Circuit Court Clerk Rush Co. Circuit Court Clerk
nd
P.O. Box 739 P.O. Box 599 MIAMI 101 East 2 Street WASHINGTON
Washington, IN 47501 - 0739 Danville, IN 46122 - 0599 Miami Co. Circuit Court Clerk P.O. Box 429 Washington Co. Circuit Court Clerk
(812) 254-8679 (317) 745-9313 P.O. Box 184 Rushville, IN 46173 - 0429 99 Public Square North
Peru, IN 46970 - 0184 (765) 932-4522 Salem, IN 47167 - 2098
DEARBORN HENRY (765) 472-3901 ext. 226 (812) 883-5748
Dearborn Co. Circuit Court Clerk Henry Co. Board of Voter Registration ST. JOSEPH
215 W. High Street P.O. Box B MONROE St. Joseph Co. Board of Voter Registration WAYNE
th
Lawrenceburg, IN 47025 - 1909 New Castle, IN 47362 - 1044 Monroe Co. Board of Voter Registration City-County Building, 4 Floor Wayne Co. Circuit Court Clerk
(812) 537-8869 (765) 529-3000 301 North College Avenue, Room 202 227 West Jefferson Boulevard 301 E. Main Street
Bloomington, IN 47401 - 3865 South Bend, IN 46601 - 1871 Richmond, IN 47374
DECATUR HOWARD (812) 349-2690 (574) 235-9520 (765) 973-9304
Decatur Co. Circuit Court Clerk Howard Co. Board of Voter Registration
150 Courthouse Square 104 North Buckeye Street, Room 104B MONTGOMERY SCOTT WELLS
Suite 244 Kokomo, IN 46901 - 4667 Montgomery Co. Circuit Court Clerk Scott Co. Circuit Court Clerk Wells Co. Circuit Court Clerk
Greensburg, IN 47240 - 2080 (765) 456-2219 100 East Main Street, Room 203 1 East McClain Avenue 102 West Market Street
(812) 663-8223 P.O. Box 768 Scottsburg, IN 47170 - 1885 Suite 201
HUNTINGTON Crawfordsville, IN 47933 - 0768 (812) 752-8420 Bluffton, IN 46714 - 2091
DEKALB Huntington Co. Circuit Court Clerk (765) 364-6437 (260) 824-6480
Dekalb Co. Circuit Court Clerk P.O. Box 228 SHELBY
P.O. Box 230 201 North Jefferson Street MORGAN Shelby Co. Circuit Court Clerk WHITE
100 S. Main Street Huntington, IN 46750 Morgan Co. Circuit Court Clerk P.O. Box 198 White Co. Circuit Court Clerk
Auburn, IN 46706 - 0230 (260) 358-4820 P.O. Box 1556 Shelbyville, IN 46176 - 0198 P.O. Box 350
(260) 925-9787 Martinsville, IN 46151 - 1556 (317) 392-6324 Monticello, IN 47960 - 0350
JACKSON (765) 342-1029 (574) 583-1531
DELAWARE Jackson Co. Circuit Court Clerk SPENCER
Delaware Co. Board of Voter Registration 111 South Main Street NEWTON Spencer Co. Circuit Court Clerk WHITLEY
100 West Main Street, Room 200 P.O. Box 122 Newton Co. Circuit Court Clerk P.O. Box 12 Whitley Co. Circuit Court Clerk
Muncie, IN 47305 - 2836 Brownstown, IN 47220 -0122 P.O. Box 49 200 Main Street 101 West Van Buren Street
(765) 747- 7812 (812) 358-6120 Kentland, IN 47951 - 0049 Rockport, IN 47635 - 0012 Columbia City, IN 46725 - 2087
(219) 474-6081 (812) 649-6017 (260) 248-3164
JASPER
Jasper Co. Circuit Court Clerk
115 West Washington
Rensselaer, IN 47978
(219) 866-4929