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Medical Services – Appendix V, Voter Registration Page 3 of 3 Customer Declination If the customer declines to register to vote, then she/he will be asked to make the declination by checking "no" on the Agency-Based Declaration Statement. She/he should also sign and date the statement. If the customer refuses to complete the form, the DCO employee will print the customer’s name on the statement, date, and make a note of "refused to sign" in the comment section. A copy of the Agency-Based Declaration Statement may be provided to the customer if requested. A daily count of the declinations must be provided to the Secretary of State’s office when completing the Agency Daily Recap Reporting Form. The Agency Based Declaration Statement will be kept for 2 years in the County Office in a chronological file by month and year. Change of Address or Name Change If a customer reports a change of address or name change, a DCO-131, Voter Registration change of Status form and a Voter Registration Application will be sent to the customer advising that the change can be reported to the County Clerk’s office for voter registration purposes or that she/he can register to vote. A declaration statement will not be completed in this instance. Submitting Applications Completed Voter Registration Applications must ensure that this timeframe is met. The customer may mail his/her application; the address is on the back of the application. An envelope is not needed. An Agency Daily Recap Reporting Form will be completed and sent with the voter registration application. This form advises the Secretary of State’s Office of the number of declination and number of completed voter registration applications being submitted. A single report including all programs will be submitted. The County Office will retain a copy of the Daily Recap Reporting form for 24 months in a chronological file by month and year. The County office must maintain a record of the number of Voter Registration applications mailed to the Secretary of State’s Office each day. No later than the 10th calendar day of each month, the county will report to the DCO Field Operations, via the DHS-132, Voter Registration Application Monthly Report, the number of voter registration applications and declinations submitted to the Secretary of State’s office in the prior month.