GN-3180, 09/16 Notice of Voting Eligibility 24724754.25(2)(c)(1)(g) and 54.64(2) ,Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE MATTER OF Name Date of Birth Amended Notice of Voting Eligibility Case No. TO: State of Wisconsin/Wisconsin Elections Commission 212 East Washington Avenue, 3rd Floor P. O. Box 7984 Madison, Wisconsin 53707-7984 The circuit court declared on [Date] that Party/full name: Party/primary address: Party/second address: Party/city Party/State Party/Zip: Date of birth: is not competent to exercise the right to register to vote or to vote in an election. has been restored the right to register to vote and to vote in an election. FOR OFFICE USE ONLY Wisconsin Elections Commission Date Processed Staff American LegalNet, Inc. www.FormsWorkFlow.com