At-Risk Designation Form

At-Risk Designation Request Form
Utah Code 20A-2-606
What does this request do?
State law allows certain non-government individuals and organizations to obtain some of your voter registration information. This form allows certain individuals to request that their voter registration record is classified as at-risk. Personally identifiable information will not be publicly released. The information that must be provided is the residential/mailing address, party affiliation and age range of the voter.
Please provide your personal information:
Full Name*
Date of Birth (So we can identify your voter record in our system)*

MonthDayYear
Date
Phone Number or Email Address (to contact you regarding this form if necessary)*
Address (Optional, but helps us to locate your voter record)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Utah law only allows certain categories of individuals to withhold their voter registration records from disclosure.
Please indicate the category that applies to you:

**Note: "Public figure" means an individual who, due to the individual being considered for, holding, or having held a position of prominence in a public or private capacity, or due to the individual's celebrity status, has an increased risk to the individual's safety. It also includes an individual who is elected to public office, appointed to fill a vacancy in an elected public office, or employed by a government entity if, in relation to the individual's service in public office or employment as an employee of a government entity, the individual has received a threat of harm to a person or property.
I am applying for designation as an at-risk voter because I am, or I reside with:*

An individual who is a victim of, or who is threatened with, domestic violence or dating violenceA law enforcement officerA public figure (Definition Utah Code 20A-1-102(62)**A member of the armed forcesAn individual protected by a protective or protection order
Please provide a statement below that explains why you meet the category you indicated above. This section is not required if you are a victim of domestic violence or dating violence, you are likely to be a victim of domestic or dating violence, you reside with an individual who is a victim of domestic or dating violence, or you reside with an individual who is likely to be a victim of domestic violence or dating violence. Attach additional sheets if necessary. Your election official may require you to provide additional documentation to verify that you meet the category that you indicated above.
Read the disclaimer statement below and then sign and date.
Submitting this request limits the disclosure of your voter registration record after this form has been processed by the election official. Submitting this form does not remove or prevent the disclosure of your personal information that may be located in other government or commercial databases. Unless you are or likely to be a victim of domestic violence or dating violence, or an individual who resides with an individual who is or likely to be a victim of domestic violence or dating violence, the election official may request additional documentation to verify that you meet the category that you indicated above.
Signature: I declare under penalty of perjury under the laws of the state of Utah that the foregoing is true and correct*
Submit this completed form to your county clerk's office or to the Office of the Utah Lieutenant Governor. You may submit this form via mail, email, or you may drop it off in person.
Today's Date

MonthDayYear
Date
Cache County Clerk's Office

179 N. Main St, Suite 102

Logan, UT 84321

Email: elections@cachecounty.gov

Office of the Utah Lieutenant Governor
Mailing Address: Utah State Capitol, Suite 220
PO Box 142325
Salt Lake City, UT 84114
Email: elections@utah.gov
Form date: 4/26
Should be Empty:

At-Risk Designation Request Form

What does this request do?

Please provide your personal information:

Please indicate the category that applies to you:

Read the disclaimer statement below and then sign and date.