“AFFIRMATION

     Are you a citizen of the United States of America? Yes No

     Will you be 18 years old on or before election day? Yes No

     If you checked “no” in response to either of the two above questions, do not complete this form.

     Name of Voter _________________________________________________________

                    First                Middle               Last

     Driver License or Identification Card Number _________________________________

     State of Issuance of Driver License or Identification Card Number _________________

     Date of Birth ___________________________________________________________

     Street Address of Principal Place of Residence

     ______________________________________________________________________

          City               County               State          Zip Code

     Telephone Number (optional) ______________________________________________

     Email Address (optional)__________________________________________________

     Last four digits of Social Security Number ____________________________

     Last former address at which I was registered to vote (if known)

     ______________________________________________________________________

          City               County               State          Zip Code

     Voting Precinct (if known) _________________________________________________

     I, (please print your full name)__________________________do solemnly swear or affirm:

     That I am eligible to vote in this election; that I have not voted in this election in any other precinct; that I am eligible to vote in this precinct; and that I request that I be permitted to vote in this precinct; and

     Subject to penalty of law for false statements, that the information contained in this form is true, and that I am a citizen of the United States and a resident of Utah, residing at the above address; and that I am at least 18 years old and have resided in Utah for the 30 days immediately before this election.

     Signed ______________________________________________________________________

     Dated ______________________________________________________________________

     In accordance with Section 20A-3a-506, wilfully providing false information above is a class B misdemeanor under Utah law and is punishable by imprisonment and by fine.

     Voter registration records contain some information that is available to the public, such as your name and address, some information that is available only to government entities, and some information that is available only to certain third parties in accordance with the requirements of law.

     Your driver license number, identification card number, social security number, email address, full date of birth, and phone number are available only to government entities. Your year of birth is available to political parties, candidates for public office, certain third parties, and their contractors, employees, and volunteers, in accordance with the requirements of law.

     You may request that all information on your voter registration records be withheld from all persons other than government entities, political parties, candidates for public office, and their contractors, employees, and volunteers, by indicating here:

     _____ Yes, I request that all information on my voter registration records be withheld from all persons other than government entities, political parties, candidates for public office, and their contractors, employees, and volunteers.

     REQUEST FOR ADDITIONAL PRIVACY PROTECTION

     In addition to the protections provided above, you may request that identifying information on your voter registration records be withheld from all political parties, candidates for public office, and their contractors, employees, and volunteers, by submitting a withholding request form, and any required verification, as described in the following paragraphs.

     A person may request that identifying information on the person’s voter registration records be withheld from all political parties, candidates for public office, and their contractors, employees, and volunteers, by submitting a withholding request form with this registration record, or to the lieutenant governor or a county clerk, if the person is or is likely to be, or resides with a person who is or is likely to be, a victim of domestic violence or dating violence.

     A person may request that identifying information on the person’s voter registration records be withheld from all political parties, candidates for public office, and their contractors, employees, and volunteers, by submitting a withholding request form and any required verification with this registration form, or to the lieutenant governor or a county clerk, if the person is, or resides with a person who is, a law enforcement officer, a member of the armed forces, a public figure, or protected by a protective order or a protection order.

     CITIZENSHIP AFFIDAVIT

     Name:

     Name at birth, if different:

     Place of birth:

     Date of birth:

     Date and place of naturalization (if applicable):

     I hereby swear and affirm, under penalties for voting fraud set forth below, that I am a citizen and that to the best of my knowledge and belief the information above is true and correct.

                                        ____________________________

                                             Signature of Applicant

     In accordance with Section 20A-2-401, the penalty for willfully causing, procuring, or allowing yourself to be registered to vote if you know you are not entitled to register to vote is up to one year in jail and a fine of up to $2,500.”

Terms Used In Utah Code 20A-6-105

• Armed forces: means the United States Army, Navy, Air Force, Marine Corps, Space Force, and Coast Guard. See Utah Code 68-3-12.5
• Ballot: means the storage medium, including a paper, mechanical, or electronic storage medium, that records an individual voter's vote. See Utah Code 20A-1-102
• Election: means a regular general election, a municipal general election, a statewide special election, a local special election, a regular primary election, a municipal primary election, and a special district election. See Utah Code 20A-1-102
• Fraud: Intentional deception resulting in injury to another.
• Person: means :
       (24)(a) an individual;
       (24)(b) an association;
       (24)(c) an institution;
       (24)(d) a corporation;
       (24)(e) a company;
       (24)(f) a trust;
       (24)(g) a limited liability company;
       (24)(h) a partnership;
       (24)(i) a political subdivision;
       (24)(j) a government office, department, division, bureau, or other body of government; and
       (24)(k) any other organization or entity. See Utah Code 68-3-12.5
• Provisional ballot: means a ballot voted provisionally by a person:
       (55)(a) whose name is not listed on the official register at the polling place;
       (55)(b) whose legal right to vote is challenged as provided in this title; or
       (55)(c) whose identity was not sufficiently established by a poll worker. See Utah Code 20A-1-102
• 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. See Utah Code 20A-1-102
• Registration form: means a form by which an individual may register to vote under this title. See Utah Code 20A-1-102
• Resident: means a person who resides within a specific voting precinct in Utah. See Utah Code 20A-1-102
• Swear: includes "affirm. See Utah Code 68-3-12.5
• United States: includes each state, district, and territory of the United States of America. See Utah Code 68-3-12.5
• Voter: means an individual who:
       (79)(a) meets the requirements for voting in an election;
       (79)(b) meets the requirements of election registration;
       (79)(c) is registered to vote; and
       (79)(d) is listed in the official register book. See Utah Code 20A-1-102