§216.EXHIBIT H. Address Correction for Fail Safe Voter

Mandated

December, 1995

SBE No. C-6

 

 

ADDRESS CORRECTION FOR FAIL-SAFE VOTER

 

□    FEDERAL  BALLOT  ONLY

 

·                     Voters who change residence to another address within Election Authority's jurisdiction.

 

·                     Voting in former residence polling place or when applying for absentee ballot.

 

 

 

Social Security Number (last four numbers:  ______________________________

 

Date of Birth:  ________________________

 

Voter's Full Name (Please Print):

 

__________________________________________________________________

 

Current Address:

 

__________________________________________________________________

 

City/Village ___________________________       Zip Code _________________

 

Former Address:

 

__________________________________________________________________

 

City/Village ___________________________       Zip Code _________________

 

 

 

 

__________________                                      _____________________________

Date                                                                   Signature of Voter or Mark