I. Any person registering to vote shall be:
(a) At least 18 years of age on the day of the next election; and
(b) A United States citizen; and
(c) Domiciled in the town or city in which the applicant is registering to vote and not otherwise disqualified to vote.
II. The applicant shall be required to produce appropriate proof of qualifications as provided in N.H. Rev. Stat. § 654:12 and fill out the form as prescribed in paragraph IV.
III. If an applicant is unable to provide the proof of qualifications as required in N.H. Rev. Stat. § 654:12, he or she may register by completing the necessary affidavits, pursuant to N.H. Rev. Stat. § 654:12, and completing the form in subparagraph IV(b), unless the person is registering within 30 days before an election or at the polling place on election day. If an applicant is registering at the polling place on election day and is unable to provide the proof of qualifications as required in N.H. Rev. Stat. § 654:12, he or she may register by completing the form in subparagraph IV(c) under oath, which oath may be witnessed by an election official or any other person, working in conjunction with the supervisors of the checklist, who is authorized by law to administer oaths, including, but not limited to, any justice of the peace or notary public; should the applicant not otherwise have proof of identity and therefore be relying upon the form for proof of identity, the act of swearing to the form shall constitute sufficient proof of identity for the purposes of any person administering the oath, notwithstanding any language to the contrary in any laws relating to the administering of oaths for other purposes.
IV. (a) Standard registration application forms shall be used throughout the state. The registration forms shall be no larger than 8
1/2 inches by 11 inches.
(b) The secretary of state shall prescribe the form of the voter registration form to be used for voter registrations, transfers, or updates other than those used within 30 days of an election or at the polling place on election day, which shall be in substantially the following form:

___ NEW REGISTRATION I am not registered to vote in New Hampshire
___ TRANSFER I am registered to vote in New Hampshire and have moved my voting domicile to a new town or ward in New Hampshire
___ NAME CHANGE/ADDRESS UPDATE I am registered to vote in this town/ward and have changed my name/address
	Date ____________________
VOTER REGISTRATION FORM
(Please print or type)
1. Name_
Last (suffix) First Full Middle Name
2. Domicile Address_
Street Ward Number
_
Town or City Zip Code
3. Mailing Address if different than in 2_
Street
_
Town or City Zip Code
4. Place and Date of Birth_
	Town or City State
Date ____________________
5. Are you a citizen of the United States? Yes _____ No _____
If a naturalized citizen, give name of court where and date when naturalized
_
6. Place last registered to vote_
	Street Ward Number
I am not currently registered to vote elsewhere (initial here __________ ), or I request that my name be removed as a registered voter in ______________________________ (fill in your address where previously registered, street, city/town, state, and zip code)
7. Name under which previously registered, if different from above
_
8. Party Affiliation (if any)_
9. Driver’s License Number _________________________ State_

If you do not have a valid driver’s license, provide the last four digits of your social security number __________
My name is ____________________ . I am today registering to vote in the city/town of ____________________ , New Hampshire. If a city, ward number __________ .
I understand that to vote in this ward/town, I must be at least 18 years of age, I must be a United States citizen, and I must be domiciled in this ward/town.
I understand that a person can claim only one state and one city/town as his or her domicile at a time. A domicile is that place, to which upon temporary absence, a person has the intention of returning. By registering or voting today, I am acknowledging that I am not domiciled or voting in any other state or any other city/town.
In declaring New Hampshire as my domicile, I realize that I am not qualified to vote in the state or federal elections in another state.
If I have any questions as to whether I am entitled to vote in this city/town, I am aware that a supervisor of the checklist is available to address my questions or concerns.
I acknowledgethat I have read and understand the above qualifications for voting and do hereby swear, under the penalties for voting fraud set forth below, that I am qualified to vote in the above-stated city/town, and, if registering on election day, that I have not voted and will not vote at any other polling place this election.

_	_
Date	Signature of Applicant

In accordance with N.H. Rev. Stat. § 659:34, the penalty for knowingly or purposely providing false information when registering to vote or voting is a class A misdemeanor with a maximum sentence of imprisonment not to exceed one year and a fine not to exceed $2,000. Fraudulently registering to vote or voting is subject to a civil penalty not to exceed $5,000.
(c) The secretary of state shall prescribe the form of the voter registration form to be used only for voter registrations, transfers, or updates starting 30 days before each election and at the polling place on election day, which shall be in substantially the following form:

___ NEW REGISTRATION I am not registered to vote in New Hampshire
___ TRANSFER I am registered to vote in New Hampshire and have moved my voting domicile to a new town or ward in New Hampshire
___ NAME CHANGE/ADDRESS UPDATE I am registered to vote in this town/ward and have changed my name/address
Date registration form is submitted _______________
Date applicant moved to the address listed below as the voter’s domicile __________
VOTER REGISTRATION FORM
FOR USE STARTING 30 DAYS BEFORE AN ELECTION AND AT THE POLLING PLACE ON ELECTION DAY
(Please print or type)
1. Name_
Last (suffix) First Full Middle Name
2. Domicile Address_
	Street Ward Number
_
Town or City Zip Code
3. Mailing Address if different than in 2_
				Street
_
Town or City Zip Code
4. Place and Date of Birth_
	Town or City State
Date ____________________
5. Are you a citizen of the United States? Yes _____ No _____
If a naturalized citizen, give name of court where and date when naturalized_
6. Place last registered to vote_
		Street Ward Number
I am not currently registered to vote elsewhere (initial here __________ ), or I request that my name be removed as a registered voter in ______________________________ (fill in your address where previously registered, street, city/town, state, and zip code)
7. Name under which previously registered, if different from above
_
8. Party Affiliation (if any)_
9. Driver’s License Number _________________________ State_

If you do not have a valid driver’s license, provide the last four digits of your social security number __________
My name is ____________________ . I am today registering to vote in the city/town of ____________________ , New Hampshire. If a city, ward number __________ .
I understand that to vote in this ward/town, I must be at least 18 years of age, I must be a United States citizen, and I must be domiciled in this ward/town.
I understand that a person can claim only one state and one city/town as his or her domicile at a time. A domicile is that place, to which upon temporary absence, a person has the intention of returning. By registering or voting today, I am acknowledging that I am not domiciled or voting in any other state or any other city/town.
In declaring New Hampshire as my domicile, I realize that I am not qualified to vote in the state or federal elections in another state.
If I have any questions as to whether I am entitled to vote in this city/town, I am aware that a supervisor of the checklist is available to address my questions or concerns.
I understand that to make the address I have entered above my domicile for voting I must have an intent to make this the one place from which I participate in democratic self-government and must have acted to carry out that intent.
I understand that if I have documentary evidence of my intent to be domiciled at this address when registering to vote, I must either present it at the time of registration or I must place my initials next to the following paragraph and mail a copy or present the document at the town or city clerk’s office within 10 days following the election (30 days in towns where the clerk’s office is open fewer than 20 hours weekly).
_____ By placing my initials next to this paragraph, I am acknowledging that I have not presented evidence of actions carrying out my intent to be domiciled at this address, that I understand that I must mail or personally present to the clerk’s office evidence of actions carrying out my intent within 10 days following the election (or 30 days in towns where the clerk’s office is open fewer than 20 hours weekly), and that I have received the document produced by the secretary of state that describes the items that may be used as evidence of a verifiable action that establishes domicile.
Failing to report and provide evidence of a verifiable action will prompt official mail to be sent to your domicile address by the secretary of state to verify the validity of your claim to a voting domicile at this address.
I understand that if I do not have any documentary evidence of my intent to be domiciled at this address, I must place my initials next to the following paragraph:
_____ By placing my initials next to this paragraph, I am acknowledging that I am aware of no documentary evidence of actions carrying out my intent to be domiciled at this address, that I will not be mailing or delivering evidence to the clerk’s office, and that I understand that officials will be sending mail to the address on this form or taking other actions to verify my domicile at this address.
I acknowledgethat I have read and understand the above qualifications for voting and do hereby swear, under the penalties for voting fraud set forth below, that I am qualified to vote in the above-stated city/town, and, if registering on election day, that I have not voted and will not vote at any other polling place this election.

_	_
Date	Signature of Applicant

If this form is used in place of proof of identity, age, or citizenship, I hereby swear that such information is true and accurate to the best of my knowledge.
This form was executed for purposes of proving (applicant shall circle yes or no and initial each item):

Identity yes/no _____
(initials)
Citizenship yes/no _____
(initials)
Age yes/no _____
(initials)
_	_
Applicant	Election Official
_
Notary Public/Justice of the Peace/Official Authorized by N.H. Rev. Stat. § 659:30

In accordance with N.H. Rev. Stat. § 659:34, the penalty for knowingly or purposely providing false information when registering to vote or voting is a class A misdemeanor with a maximum sentence of imprisonment not to exceed one year and a fine not to exceed $2,000. Fraudulently registering to vote or voting is subject to a civil penalty not to exceed $5,000. In accordance with N.H. Rev. Stat. § 659:34-a voting in more than one state in the same election is a class B felony with a maximum sentence of imprisonment not to exceed 7 years and a fine not to exceed $4,000.
V. The secretary of state shall prepare and distribute an addendum to the voter registration form used under subparagraph IV(c) to be distributed to those registrants who register within 30 days before the election or on election day and who do not provide proof of domicile or a verifiable action to demonstrate domicile. The “verifiable action of domicile” document shall provide notice of the requirements that registrants must furnish documentary evidence of domicile and shall be in substantially the following form:
Verifiable Action of Domicile
As a newly registered voter, you have received this document because you did not provide proof of domicile when you registered to vote. N.H. Rev. Stat. § 654:2, IV requires you to provide evidence that you have taken a verifiable act to establish domicile.
The following checklist shall be used as a guide for what you may use as evidence and shall be submitted to the town or city clerk along with documentation that you are required to provide. Only one item on the list is required to demonstrate a verifiable act.
To establish that you have engaged in a verifiable act establishing domicile, provide evidence that you have done at least one of the following:
___ established residency, as set forth in N.H. Rev. Stat. § 654:1, I-a, at an institution of learning at the address on the voter registration form
___ rented or leased an abode, for a period of more than 30 days, to include time directly prior to an election day at the address listed on the voter registration form
___ purchased an abode at the address listed on the voter registration form
___ obtained a New Hampshire resident motor vehicle registration, driver’s license, or identification card issued under N.H. Rev. Stat. § 260:21, N.H. Rev. Stat. § 260:21-a, or N.H. Rev. Stat. § 260:21-b listing the address on the voter registration form
___ enrolled a dependent minor child in a publicly funded elementary or secondary school which serves the town or ward of the address where the registrant resides, as listed on the voter registration form
Identified the address on the voter registration form as your physical residence address on:
___ state or federal tax forms
___ other government-issued forms or identification. Describe form of identification: _______________
___ provided the address on the voter registration form to the United States Post Office as your permanent address, provided it is not a postal service or commercial post office box, where mail is delivered to your home. This can be by listing the address on the voter registration form as your new address on a Postal Service permanent change of address form and providing a copy of the receipt, or an online emailed receipt
___ obtained public utility services (electricity, cable, gas, water, etc.) for an indefinite period at the address on the voter registration form. List services obtained: _________________________
___ arranged for a homeless shelter or similar service provider to receive United States mail on your behalf. Enter name of the shelter or provider: _________________________
___ describe what other verifiable action or actions you have taken to make the address listed on your voter registration form your one voting domicile: _________________________

If you have no other proof of a verifiable act establishing domicile, and your domicile is at an abode rented, leased, or purchased by another and your name is not listed on the rental agreement, lease, or deed, you are required to provide a written statement, signed under penalty of voting fraud if false information is provided, from a person who is listed on such document, or other reasonable proof of ownership or control of the property, attesting that you reside at that address, signed by that person or his or her agent who manages the property.
This verifiable action of domicile form, along with your written statement or other documentation proving a verifiable act, shall be delivered to the town or city clerk, by mail or in person, with 10 days, or within 30 days if the clerk’s office is open fewer than 20 hours weekly.

Name_
Last (suffix) First Full Middle Name
Domicile Address_
Street Ward Number
_
Town or City Zip Code
_	_
Date	Signature of Applicant

This document was received by the clerk, who examined and returned it to the applicant after making a copy of the evidence of verifiable action, said copy to be attached to the verifiable action of domicile form.

_	_
Date	Signature of Clerk

The clerk shall forward the completed form and attachment or attachments to the supervisors of the checklist as soon as possible, but not later than their next meeting. The supervisors of the checklist shall attach the form and attachments to the voter registration form.