Submitted by Mail Wisconsin Voter Registration Application Confidential Elector ID# (Official Use Only) SVRS ID (HINDI - sequential #) (Official Use Only) Instructions Instructions for completion 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.  If you have not voted in WI and are submitting this application by mail, you must also provide a copy of your proof of residence (see reverse).  NOTE: If this is a change of address, then upon completion of this application your voting rights will be cancelled at your previous residence. New WI Voter Name Change WI Address 1 Municipality Town Village City County Expiration Date WI Driver License or WI DOT-issued ID (DL # required if issued) 2 Social Security Number - Last Four Digits (if driver license not issued or not current and valid) XXX-XX- Print your name exactly as it appears on the document, the number of which you provided in Box 2. (Driver License/ID Card or Social Security Card). First Last Name Current 3 I have neither a WI Driver License/ID, nor a Social Security Number. Middle Name Suffix (e.g. Jr, II, etc.) Date of Birth (M/D/YYYY) Phone # Email Address Residence Address: Street Number & Name 4 Apt. If applicable 5 Previous Required 6 7 City State & ZIP Mailing Address: Street Number & Name Apt. Number City State & ZIP Last Name First Middle Name Suffix (e.g. Jr, II, etc.) Previous Registration Address : Street Number & Name Apt. State & ZIP City Accommodation needed at poll location (e.g. wheelchair access): 8 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. N  Mark crossroads Example Library  ‘X’ where you live Woodchuck Road  Use dots for landmarks X High School 9 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 or older on or before election day? 10 I hereby certify, to the best of my knowledge, 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 28 consecutive 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 sign below to acknowledge that you have read and understand the above. Yes Yes No If you filled in “No” in response to EITHER of these No questions, do not complete this form. Today’s Date Signature of 11 Elector (M/D/YYYY) X Election Day Voter # (Official use only) Falsification of information on this form is punishable under Wisconsin law as a Class I felony. Assistant Signature: (Official use only) Assistant Address: Proof of Residence # 12 (Official use only) Official’s Signature: Ward Proof of Residence type Sch. Dist. GAB-131 (REV 6/2011) SRDs printed name and SRD#: Alder Cty. Supr. 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.   1      2    3          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 from a university, college or technical college coupled with a fee receipt A picture ID from a university, college or technical college coupled with an on-campus housing listing provided by the university, college or technical college to the municipality that denotes US Citizenship  A utility bill for the period commencing not earlier than 90 days before the day registration is made A paycheck A check or other document issued by a unit of government  A bank statement Fill in the circle (New Voter, Name Change, Address Change) describing why you are completing this form. A “New Voter” is anyone who is not currently registered to vote in Wisconsin. You can check your voter registration status at Wisconsin’s Voter Public Access website (https://vpa.wi.gov) Indicate your municipality. Use formal names (For example: City of Plymouth, Village of Chenequa, or Town of Aztalan). Indicate your county of residence. If you have been issued and have a current and valid WI driver license or WI DOT-issued identification card (ID), you must provide the number. If you have been issued a WI Driver License, which is revoked, suspended, or expired, please provide the number and the last 4 digits of your Social Security number. If you have not been issued a WI driver license or a WI DOT-issued ID, you must provide the last 4 digits of your Social Security number. If you do not have a WI driver license, a WI DOT-issued ID or a Social Security number, indicate that fact by filling in the appropriate circle. If you are registering to vote on Election Day and have been issued a WI driver license, but are unable or unwilling to provide the number, your vote will not be counted unless you provide the number to the election inspectors by 8:00 p.m. on Election Day or to your municipal clerk by 4:00 p.m. the Friday following Election Day. 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, and is subject to open records requests.      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. You may not enter a PO Box as a residential address. A rural route box without a number should not be used.  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 here. 6   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   Provide your address where you were previously registered to vote. Provide this information whether you moved within Wisconsin or from another state regardless of time elapsed. 8    If you need assistance when voting, you may describe the assistance required (e.g. wheelchair access). If you are interested in being a poll worker for your municipality, you may fill in the circle. If you do not have a street address, use the map to show where you live. 4 5  9 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. If you are completing on election day you must be 18 years old today.  Please read carefully. By signing this form 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 should not sign this form.  10 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 10 of this form. Falsification of information on this form is punishable under Wisconsin law as a Class I felony. 11   12 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. GAB-131 (REV 6/2011) American LegalNet, Inc. www.FormsWorkFlow.com