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Provisional Ballot Affirmation Statement

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New Jersey Provisional Ballot Affirmation Statement 1 Reason for Provisional Ballot (Check one) ❏ Moved within the county after registering without notifying election office ❏ Registration information missing from poll book ❏ Did not show required ID ❏ “A” in poll book but did not receive, or did not apply for, an absentee ballot 2 I am a US citizen ❏ Yes 4 Current Name Last First FOR OFFICIAL USE ONLY Municipality/Ward/District: ❏ No 3 I am 18 or older ❏ Yes ❏ No MI. Suffix If your name was changed after registering to vote, provide your former name Former Name Signature of Former Name 5 Current Home Address Municipality Mailing Address, if different from above: County Zip Code 6 Please Fill Out Only if You Moved within the County after Registering Without Notifying Election Office Previous Home Address Municipality County Day Year Zip Code 7 Date of Birth Month 8 Gender ❏ Female ❏ Male 9 NJ Driver’s License (DL#) or MVC Non-driver ID (ID#) Number Telephone Number (Optional) If No DL# or ID#, last four digits of your Social Security Number (SS#) 10 ❏ I affirm that I do not have a DL#/ID# or SS# 11 Political Party Required for primary election; Optional for all other elections 12 Voter Declaration — I swear or affirm that I am a U.S. citizen, live at the address above, am at least 18 years of age at the time of the election, have been a resident of the State and county at least 30 days before the election, am not on parole, probation or serving a sentence due to the conviction for an indictable offense under any federal or State laws. I UNDERSTAND THAT ANY FALSE OR FRAUDULENT REGISTRATION MAY SUBJECT ME TO A FINE OF UP TO $15,000, IMPRISONMENT UP TO FIVE YEARS, OR BOTH PURSUANT TO R.S. 19:34-1. Signature of Voter Date Name of person providing assistance oag-saa-10.3.06 X

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