Voter Certificate Request Form
Please fill out this form completely to request a certificate of your voter record.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I will provide which of the following:
*
Utah Driver's License Number
Last 4 digits of my Social Security Number
Driver's License Number
*
Social Security Number
*
Email
*
example@example.com
Do you want your voter certificate to show your political party affiliation, if any?
*
Yes, please include my political party
No, please do NOT include my political party
How would you like to receive your ballot?
*
Please mail my ballot to me
Do NOT mail my ballot to me, I will vote in person
Signature
*
Submit
Submit
Should be Empty: