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iii COMMONWEALTH OF VIRGINIA VOTER REGISTRATION AGENCY CERTIFICATION

If you are not registered to vote where you live now, would you like to apply to register to vote here today? (Please check only one)

 I am already registered to vote at my current address, or I am not eligible to register to vote and do not need an application to register to vote.  Yes, I would like to apply to register to vote. (Please fill out the voter registration application form)  No, I do not want to register to vote.

If you do not check any box, you will be considered to have decided not to register to vote at this time. Applying to register to vote or declining to register to vote will not affect the assistance or services that you will be provided by this agency.

If you decline to register to vote, this fact will remain confidential. If you do register to vote, the office where your application was submitted will be kept confidential, and it will be used only for voter registration purposes.

If you would like help filling out the voter registration application form, we will help you. The decision whether to seek or accept help is yours. You may fill out the application form in private if you desire.

If you believe that someone has interfered with your right to register or to decline to register to vote, your right to privacy in deciding whether to register or in applying to register to vote, you may file a complaint with: Secretary of the Virginia State Board of Elections, Washington Building, 1100 Bank Street, Richmond, VA 23219-3497, Telephone (804) 864-8901.

__________________________________ _________________________________ _______________________ Applicant Name Signature Date for agency use only

Voter Registration form completed:  Yes  No Voter Registration form given to applicant for later mailing (at applicant’s request)  Yes  No ___________________________________________ _______________________________

Agency Staff Signature Date: