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STATE OF HAWAII NATIONAL VOTER REGISTRATION ACT QUESTIONNAIRE If you are not registered to vote where you live now, would you like to apply to register to vote here today?  Already registered I am registered to vote at my current residence address.  YES I would like to register to vote. (Please fill out the Voter Registration Application.)  NO I do not want to register to vote. If you do not check a box, you will be considered to have decided not to register to vote at this time. Print Name Signature Date Office Use Only Applicant declined to sign questionnaire State Agency ID: A017 Rev. 2021 English Important Notices Applying to register or declining to register to vote will not affect the amount of assistance that you will be provided by this agency. If you would like help filling out the voter registration application, we will help you. The decision to seek or accept help is yours. You may fill out the application in private. If you believe that someone has interfered with your right to register or to decline to register to vote, or your right to privacy in deciding whether to register or in applying to register to vote, you may file a complaint with the Office of Elections by phone (808) 453-VOTE (8683) or toll free at 1-800-442-VOTE (8683) or by mail to Office of Elections, 802 Lehua Avenue, Pearl City, Hawaii 96782. Attachment A-2, Page 16 of 18