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Source page 1
Massachusetts Official
William Francis Galvin
Mail-In Voter Registration Form Secretary of the Commonwealth
How to use this form
1. Check all the boxes that apply to you. You can use this form to:
2. Print your name: last name, first name, middle name or initial. • register to vote in Massachusetts; and/or
3. Print your former name, if applicable. • change your name or address for voter registration only; and/or
4. Print the address where you live now: number and street name or rural • join a party, change from one party to another or leave a party.
route number and box number (do not provide a post office box number), To register to vote in Massachusetts you must:
apartment number, city or town and full zip code. Use the map† at right if • BE A U.S. CITIZEN; and
you cannot otherwise identify your address. • be a Massachusetts resident; and
5. Print the address where you receive all your mail, if it is different from the • be at least 18 years old on or before the next election.
address entered on #4. Penalty for Illegal Registration: Fine of not more than
6. Print your date of birth: month, day and year. $10,000 or imprisonment for not more than five years or both.
7. Federal law requires that you provide your driver’s license number to -Massachusetts General Laws, chapter 56 section 8.
register to vote. If you do not have a current and valid Massachusetts driver’s
license, you must provide the last four digits of your social security number. Identification To Be Provided
If you have neither, you must write “none” in the box. Section 7 requires you to include your driver’s license number or the last 4
8. It is optional to provide your telephone number. If you include your tele- digits of your social security number on this application. This information will
be verified through the Registry of Motor Vehicles and the Commissioner of
phone number and do not check “unlisted” it will be a public record. Social Security. If the information cannot be verified or you do not provide this
9. Check a party, ‘no party’ or print a political designation (not a party). information, you must provide identification either with this application or at
10. Print the address where you were last registered to vote. your polling location when you go to vote. Sufficient identification includes a copy
11. If a person is helping you because you are physically unable to sign this of a current and valid photo identification, current utility bill, bank statement,
form, that assisting person must print his or her name and address and has government check, paycheck or other government document showing your name
and address.
the option to print his or her telephone number.
12. Read the oath. north †
Using landmarks, draw the
13. Print today’s date.
location of the place where you
14. Sign your name. west east
live if you cannot describe that
This form may be mailed or hand-delivered to your city or town hall. If mailed,
location as a number and street or
fold the form, tape it closed, place a first class stamp on it, print your city or south as a rural route and box number.
town name and zip code for that city or town hall and drop into any mailbox.
Follow the instructions listed above for proper delivery.
1 Check all that apply: Are you a Citizen of the United States of America? ■ Yes ■ No
Will you be 18 years of age or older on or before Election Day? ■ Yes ■ No
NOTE: If you checked “no” to either of these questions, do not complete this form.
Full name:
2 Miss Ms. Mrs. Mr. last name first name middle name or initial.
Jr. Sr. II III IV
(circle one if appropriate)
3 Former name (if applicable): last name
Miss Ms. Mrs. Mr.
first name middle name or initial.
Jr. Sr. II III IV
(circle one if appropriate)
4 Address where you live now (street number, street name, rural route number and box number):
street number / street name / rural route number and box number apartment number city or town zip code + 4-digit
5 Address where you receive all your mail (if different from #4):
street number / street name / rural route number and box number apartment number city or town zip code + 4-digit
6 Date
month
of birth:
day year 7 Identification #:
MA license # or last 4 digits of your SS # 8 Telephone (optional): ■ Check if unlisted
( )
9 Party enrollment or designation (check one): ■ Democratic ■ Republican
■ No Party (unenrolled) ■ Political Designation (not a political party):
10 Address at which you were last registered to vote:
street number / street name / rural route number and box number / post office box apartment number city or town state zip code + 4-digit
11 Ifname
the applicant is unable to sign this form, give the name, address and telephone number (optional) of the person helping the applicant:
address telephone number (optional)
12 Iunder
hereby swear (affirm) that I am the person named above, that the above information is true, that I AM A CITIZEN OF THE UNITED STATES, that I am not a person
a guardianship which prohibits my registering to vote, that I am not temporarily or permanently disqualified by law from voting because of corrupt practices in respect to elections,
that I am not currently incarcerated for a felony conviction, and that I consider this residence to be my home. Signed under the penalty of perjury.
13 Today’s date: month day year
14 Signed: Sign your name here.Source page 2
Place tape here to close. Do not use staples
This form must be received by the local Board of Registrars or Election
Commission or postmarked on or before the deadline for voter registration
(listed below) for that election, primary, preliminary or town meeting.
DEADLINES FOR VOTER REGISTRATION
Check to make
sure that you have To participate in... You must register...
completed all state primaries
the information state elections
on the voter city and town preliminaries at least 20 days before
registration city and town elections
affidavit on the regularly scheduled town meetings
opposite side!
special town meetings at least 10 days before
If you do not hear from your local election officials in 2 or 3 weeks, please call them!
Fold along dotted line.
Return Address
Place
name
First Class
number and street
MA Stamp Here
city or town zip code
Board of Registrars or Election Commission
City or Town Hall
MA
YOUR CITY OR TOWN ZIP CODE FOR CITY OR TOWN HALL