§216.EXHIBIT B. Voter Registration Information

Mandated

July, 1995

SBE No. R-24

 

VOTER  REGISTRATION  INFORMATION

 

"If you are not registered to vote where you live now, would you like to apply to register here today?"

IMPORTANT!

 

(Public assistance agencies include the following: "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 form, we will help you.  The decision whether to seek or accept help is yours. You may fill out the application in private.

 

IF YOU DO NOT CHECK EITHER BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER TO VOTE AT THIS TIME.          □YES                □NO __________________________________________ Signature	All information will remain confidential and will be used only for voter registration purposes.  Anyone not choosing to register to vote and/or information regarding the office to which the application was submitted will remain confidential, to be used only for voter registration purposes.     ___________________________________ Please Print Full Name
month                                day                                        year   ____________________________________________________ Date

 

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------------------------------------------------------------------------------------------------------------COMPLAINT INFORMATION

If you believe that someone has interfered with your right to register or decline to register to vote, your right to privacy in deciding whether to register or in applying to register to vote, or your right to choose your own political party or other political preference, you may file a complaint with Ronald D. Michaelson, Executive Director, State Board of Elections, 1020 South Spring Street, Springfield, Illinois 62704-2999 [phone] or TDD [phone].

 

(Half 8 ½" x 11" sheet)