Print Form This form is available in an accessible format, upon request. Submitted by Mail Wisconsin Voter Registration Application Confidential Elector ID# (HINDI - sequential #) (Office Use Only) Instructions 1 (Office Use Only) SVRS ID # (Office Use Only) Instructions for completing sections 1-12 are on the back of this form. Return this form to your municipal clerk, unless directed otherwise. Please use uppercase (CAPITAL) letters only. Fill in circles as appropriate. NOTE: If this is a change of address, then upon completion of this application your voting rights will be cancelled at your previous residence. If you have not voted in WI and are submitting this application by mail, you must also provide a copy of an acceptable proof of residence New WI Voter Name Change WI Address Change Town Village City Municipality County Wisconsin Driver License/ID Number - 2 Social Security Number - Last Four Digits (only if no license/ID number) I have neither a WI Driver License/ ID nor a Social Security Number. XXX-XX- Print your name exactly as it appears on the document, the number of which you provided in Box 2. Last Name (Driver License/ID Card or Social Security Card). First Name 3 Middle Name Date of Birth (M/D/YYYY)) Current 4 Suffix (e.g. Jr, II, etc.) Phone # Email Address Residence Address: Street Number & Name Apt. Number City State ZIP + 4 Mailing Address: Street Number & Name 5 Apt. Number City State ZIP + 4 Last Name 7 Previous 6 First Name Middle Name Suffix (e.g. Jr, II, etc.) Address: Street Number & Name Apt. Number 8 9 City State & Zip + 4 Please answer the following questions by filling in “Yes” or “No”: 1. Are you a citizen of the United States of America? 2. Will you be 18 years of age on or before election day? Yes Yes No No If you filled in ‘No” in response to EITHER of these questions, do not complete this form. I certify that I am a qualified elector, a U.S. citizen, at least 18 years old or will be at least 18 years old at the time of the next election, having resided at the above residential address for at least 10 days immediately preceding this election, with no present intent to move. I am not currently serving a sentence including probation or parole for a felony conviction, and not otherwise disqualified from voting. I certify that all statements on this form are true and correct. If I have provided false information I may be subject to fine or imprisonment under State and Federal laws. If completed on Election Day: I further certify that I have not voted in this election. (Please fill in circle.) Accommodation needed at poll location (e.g. wheelchair access): 10 I am interested in being a poll worker. If you do not have a street number or address, use the map to show where you live. Mark crossroads „X‟ where you live Use dots for landmarks N Example Library Woodchuck Road High School X Today‟s Date (M/D/YYYY) Signature of 11 Elector X Official Use Only: Election Day Voter # Corroborator/Assistant Signature: Corroborator / Assistant Address: Office Use: Proof of residence type 12 Office Use: Proof of Residence # Official‟s Signature: Ward Sch. Dist. SRDs printed name and SRD#: Alder Cty. Supr. EB-131 (UNSHADED, WITHOUT HASHMARKS) (REV 10/2008) Ct. of App. Assembly St. Senate Congress American LegalNet, Inc. www.FormsWorkflow.com Wisconsin Voter Registration Application Instructions Each section on the front side of this document corresponds to the sections below (1-12) These documents constitute proof of residence if they: Contain the voter’s current and complete first and last name and residential address, and are valid on the day used to register to vote. A current and valid WI Driver License / ID Card Any other official identification card or license issued by a Wisconsin governmental body or unit An employee ID card with a photograph, but not a business card A real property tax bill or receipt for the current year or the year preceding the date of the election A residential lease (Does not count as proof of residence if elector submits form by mail) A picture ID or fee card from a university, college or technical college A utility bill for the period commencing not earlier than 90 days before the day registration is made A bank statement A paycheck 1 Fill in the circle (New Voter, Name Change, Address Change) describing why you are completing this form. If your municipal information has not been preprinted, indicate your municipality and county of residence. Use formal names (For example: City of Plymouth, Village of Chenequa, or Town of Aztalan). If in doubt, contact your municipal clerk. 2 Provide your WI Department of Transportation (DOT) Driver License Number. If you do not have a current and valid WI Driver License, but do have a WI DOT-issued Identification (ID) Card, provide that number. If you do not have a WI DOT Driver License or ID Card, provide the last 4 digits of your Social Security Number. If you have none of these, indicate that fact by filling in the appropriate circle. If you have a WI Driver License, but do not provide the number, your registration application cannot be processed. If you are registering to vote on Election Day and you have a WI Driver License, but do not provide the number, your vote will not be counted unless you provide the number by the close of the polls or by 4 pm the following day to your municipal clerk. 3 Provide your current and complete name as it appears on the document, the number of which you provided in Box 2, including your last name, first name, middle name or initial and suffix (Jr, Sr, etc), if any. Provide your month, day and year of birth. Remember to use your birth year, not the current year. Providing your phone number and/or email address is optional, but will help your municipal clerk to contact you in case of problems with your registration. 4 Provide your home address (legal voting residence), which must be located in Wisconsin. Record the full house number (including fractions, if any). Provide your full street name, including the type (St, Ave, etc) and any pre- and/or post-directional (N, S, etc.). Provide the city name and zip that appears on mail delivered to your home address. A 5-digit zip is acceptable. You may not enter a PO Box as a residential address. A rural route box without a number should not be used. 5 If your mailing address is different from your home address, provide it here. A PO Box is acceptable as a mailing address. Overseas electors should provide their complete overseas address. 6 If your name has changed, provide your previous first, last and middle names, along with a suffix, if any. Provide this information regardless of the time elapsed since your last name change. 7 If your residential address has changed, provide your previous address here. Provide this information whether you moved within Wisconsin or from another state regardless of time elapsed. 8 Answer both questions by filling in the appropriate circle. If you answer “No” to either question, you are not eligible to vote in Wisconsin. Please note, for Question 2, you must either be at least 18 years old, or will be at least 18 years old at the time of the next election to be eligible to vote. 9 Please read carefully. By filling in this circle you are certifying that you meet the eligibility requirements to vote. If you do not meet these requirements, you are not eligible to vote in Wisconsin, and do not fill in this circle. 10 If you need assistance when voting, describe the assistance required (e.g. wheelchair access). If you are interested in being a poll worker for your municipality, fill in the circle. If you do not have a street address, use the map to show where you live. 11 By signing and dating this form, you certify that all the information you have provided on this form is true and correct, and that you meet the eligibility requirements for voting, listed in the statement in Box 9 of this form. 12 Corroborator: If you are registering on Election Day or after the official close of registration (5 pm on the 20th day before an election), you must provide proof of residence. If you are unable to do so, another qualified elector of the municipality may do so on your behalf. That corroborator must record his or her signature and address on the form in the space provided. Assistant: If you are unable to sign this form due to a physical disability, you may have an assistant do so on your behalf. That assistant must provide his or her signature and address in the space provided. By signing, the assistant certifies that he or she signed the form at your request. EB-131 INSTRUCTIONS (UNSHADED, WITHOUT HASHMARKS) (REV 10/2008) American LegalNet, Inc. www.FormsWorkflow.com