45 C.F.R. PART 801—VOTING RIGHTS PROGRAM
Title 45 - Public Welfare
Authority: 5 U.S.C. 1103; secs. 7, 9, 79 Stat. 440, 411 (42 U.S.C. 1973e, 1973g).
Source: 30 FR 9859, Aug. 7, 1965, unless otherwise noted.
Note: Those amendments to appendixes A, B, and D in Part 801, which apply to Texas, appearing at 41 FR 16155, Apr. 16, 1976, are also carried in Spanish at the end of appendix D. In this part: (a) Act means the Voting Rights Act of 1965, Public Law 89–110, as amended by Public Law 94–73, August 6, 1975. (b) Applicant means a person who presents himself to an examiner at one of the times and places designated by the OPM under §801.202 for the purpose of being listed as eligible to vote; (c) Applications means the form prescribed by the OPM under the Act for use by a person applying for listing on an eligibility list; (d) OPM means the U.S. Office of Personnel Management; (e) Day means a calendar day; (f) Eligibility list means a list of eligible voters or supplements to a list of eligible voters, prepared by an examiner under the Act; (g) Examiner means a person designated or appointed by the OPM under the Act to examine applicants for listing on an eligibility list and to prepare and maintain lists of persons eligible to vote in Federal, State, or local elections; (h) Hearing officer means a person authorized by the OPM to adjudicate a challenge to a listing on an eligibility list; (i) Political subdivision, vote, and voting have the meanings given these terms in the Act; and (j) Parties means a challenger, a challenged person, and the representative of either. [30 FR 9059, Aug. 7, 1965, as amended at 41 FR 16155, Apr. 16, 1976] A document or other paper required to be filed within a time limit specified in this part shall be delivered to the office involved before the close of business on the last day of the period, or if filed by mail be postmarked before midnight of the last day of the period. In computing a period of time prescribed by this part, the day of the action or event after which the designated period of time begins to run is not to be included. The last day of the period so computed is to be included unless it is a Saturday, Sunday, or legal holiday in the State involved, in which event the period runs until the end of the next day which is neither a Saturday, Sunday, nor a legal holiday. In this part: (a) Words importing the singular include and apply to several persons, parties, or things; (b) Words importing the plural include the singular; and (c) Words importing the masculine gender include the feminine as well. This subpart prescribes the times, places, and procedures for listing on an eligibility list under the Act. (a) The times and places designated by the OPM for filing an application in each political subdivision, and the forms of application prescribed by the OPM, shall be set out in appendix A to this part and incorporated in and made a part of this section. (b) The OPM shall give notice to the general public of the times and places designated under paragraph (a) of this section, to appropriate local election officials in the political subdivision, and to the attorney general of the State, by publication thereof in the (a) An applicant may obtain an application at the place and during the times set out in appendix A for the appropriate political subdivision. An application may be completed only at the place where it was obtained and shall be submitted by the applicant in person to an examiner at that place. (b) An examiner shall review the application in the presence of the applicant to insure that all questions are answered clearly and completely. If all questions are not answered clearly and completely or if an applicant is not able personally to complete the application in whole or in part because of lack of literacy or otherwise, or has difficulty in doing so, an examiner shall orally examine the applicant and record the pertinent information on the application or otherwise assist the applicant in completing the application. (c) After an application is completed, an examiner shall require the applicant to take the oath or affirmation prescribed on the application and to sign his name or make his mark thereon. The qualifications required for listing, prescribed by the OPM after consultation with the Attorney General, for use by an examiner in examining an applicant for listing on an eligibility list shall be set out in appendix B to this part and incorporated in and made a part of this section. At the time of filing the application and in the presence of the applicant, the examiner shall review the application and make such examination as is necessary to determine whether the applicant has the prescribed qualifications. If the applicant has the prescribed qualifications, the examiner shall give him a certificate, on the form prescribed by the OPM, evidencing his eligibility to vote and enter his name on an eligibility list, the form for which is prescribed by the OPM. If the applicant does not have the prescribed qualifications, the examiner shall give him a notice of ineligibility for listing, on the form prescribed by the OPM. An applicant may obtain a review of a notice of ineligibility for listing by executing the request for review contained on that notice and returning it to the examiner or by filing a written request, either personally or through a representative, with the Examiner (State Supervisor), U.S. Office of Personnel Management, in the State involved at the address set out in appendix C to this part and incorporated in and made a part of this section. The request shall be submitted within 10 days from the date of the notice of ineligibility for listing. The request shall set forth the applicant's reason for contesting the notice of ineligibility for listing. The Examiner (State Supervisor) shall notify the applicant or his representative and the examiner concerned of his decision. When the Examiner (State Supervisor) finds the applicant has the prescribed qualifications, he shall direct the examiner concerned to give the applicant a certificate evidencing his eligibility to vote and to enter his name on the eligibility list. There is no administrative appeal from the decision of an Examiner (State Supervisor). An examiner shall certify and transmit an eligibility list at least once a month to the office of the appropriate election official, with a copy to the Attorney General and the attorney general of the State. The list shall contain the name of each eligible voter listed since the last list was certified and transmitted. The list shall be made available for public inspection beginning on the last business day of the month and in any event not later than the 45th day before an election, during normal business hours, for one period of 10 consecutive days, at the place where the persons listed filed their applications as set out in appendix A to this part, except that the list may be made available for public inspection in the same political subdivision at a place other than the place where the persons listed filed their applications when advance notice of this change is posted at the place where the persons listed filed their applications. [30 FR 12392, Sept. 29, 1965] This subpart prescribes the procedure that governs a challenge to a listing on an eligibility list under the Act. A challenge to a listing on an eligibility list may be made only on the basis of fraud or that the challenged person does not have the prescribed qualifications. A challenge shall be filed within 10 days after the listing of the challenged person is made available for public inspection as provided in §801.207 by delivering or mailing the challenge to the Examiner (State Supervisor), U.S. Office of Personnel Management, in the State involved at the address set out in appendix C to this part. (a) A challenge shall be under oath and shall contain: (1) The name and address of the OPM office to which it is submitted; (2) The date of submission; (3) The name and address of the challenger; (4) The name and address of his representative, if any; (5) The name and address of the challenged person and his certificate number as they appear on the eligibility list; (6) A written statement setting forth in plain and concise language the facts constituting the grounds for challenging the listing of the challenged person on the eligibility list; (7) Affidavits of at least two persons (one of whom may be the challenger) with their addresses, stating that they have personal knowledge of the facts that constitute the grounds for challenge and setting forth those facts in plain and concise language. Each affidavit shall be sworn to before a person authorized to administer oaths; and (8) A certification that service of the challenge on the challenged person has been made as required by paragraph (b) of this section. (b) The challenger shall file his challenge in triplicate and shall have a copy of it served on the challenged person. That service may be in person or by first-class mail properly addressed with charges prepaid. (a) When a challenge is not timely filed or served or does not meet the requirements of §801.304, it shall not be entertained but shall be rejected. (b) When a challenge is not rejected under paragraph (a) of this section, the hearing officer shall place it on the docket. If on review of a challenge a hearing officer determines that the information, even if true and known at the time of listing, would not have disqualified the challenged person, he shall issue a decision denying the challenge without further proceeding and notify the parties of his reasons for this decision. After docketing, and if not denied under §801.306, the challenge shall be set for hearing. The challenger and the challenged person shall be sent a notice of the date, time, and place of the hearing and advised of the rights and duties of the parties including the right to request a subpena. The notice of hearing shall be dated and the date of the hearing shall not be less than 5 days from the date of that notice. The notice of hearing shall be served on the challenger and the challenged person either personally or by mail. (a) The challenger has the burden of proceeding and proof at the hearing and shall appear personally or with a representative to prosecute the challenge, except that when a continuance is sought the challenger may appear by a representative. If a challenger fails to appear personally to prosecute the challenge, the hearing officer shall issue a decision denying the challenge or make such other disposition as is warranted by the circumstances. (b) The challenged person has the right to appear at the hearing personally or by or with a representative, and to present witnesses and documentary evidence in his behalf. A request for a continuance of a hearing shall be filed with the hearing officer at the place and on the day of the hearing. The hearing officer shall not grant a continuance except under extraordinary circumstances. A hearing shall be open to the public and held at the time and place specified in the notice of hearing. A hearing shall be recorded by an official reporter designated by the OPM, under the supervision of the hearing officer. A party may obtain a copy of the transcript from the official reporter at a rate not in excess of the maximum rate fixed by contract between the OPM and the reporter. In addition to the powers otherwise vested in a hearing officer by this subpart, a hearing officer shall have the power to: (a) Administer oaths and affirmations; (b) Issue and quash subpenas; (c) Regulate the course of the hearing; (d) Rule on offers of proof; (e) Permit a party to withdraw from a hearing on a showing of good cause; (f) Limit the number of witnesses whose testimony would be cumulative; (g) Deny a challenge for failure to prosecute; (h) Exclude any person from the hearing for contumacious conduct or misbehavior that obstructs the hearing; and (i) Take any other action in the course of the hearing consistent with law that is necessary to carry out the spirit and intent of the Act. (a) A witness shall testify under oath or affirmation and shall be subject to cross-examination. (b) A witness who is summoned and responds is entitled to the same witness and mileage fees as are paid for like service in the courts of the United States. The party at whose instance the testimony is taken shall pay the witness and mileage fees. (a) On the request of a party and for good cause shown, a hearing officer may issue a subpena for the appearance of a witness or for the production of documentary evidence. (b) A hearing officer may quash a subpena for good cause shown. (c) The party at whose request a subpena is issued is responsible for arranging for service. The officer or person making service shall show the original subpena to the person served, read the subpena to him if he is unable to read, and deliver a copy of the subpena to him. (d) When a U.S. Marshal or his deputy serves a subpena, he shall evidence the service by his return on the subpena. When someone other than a U.S. Marshal or his deputy serves a subpena, the person serving the subpena shall make an affidavit, stating the date, time, and the manner of service, and shall return the affidavit on, or with, the original subpena in accordance with the form thereon. When the U.S. Marshal, his deputy, or other person, as appropriate, cannot serve the subpena, he shall state his reason for the failure on the original subpena. When the person named in the subpena accepts service of the subpena in writing, no other evidence of return is necessary. The person responsible for serving a subpena shall return the original subpena, bearing or accompanied by the required return, affidavit, statement, or acceptance of service, to the officer presiding at the hearing at which the person subpenaed is required to appear. (a) The application of the challenged person is prima facie evidence that he has the qualifications that are stated in the application. (b) Rules of evidence are not strictly applied but the hearing officer shall exclude irrelevant or unduly repetitious evidence. (c) Each exhibit of a documentary character shall be submitted to the hearing officer, duly marked, and made a part of the record. An exhibit does not become evidence unless received in evidence by the hearing officer. The hearing officer who presided at the hearing, unless he has become unavailable, shall decide the case on the record. If no hearing is held, the hearing officer to whom the challenge was assigned shall decide the case on the record. The decision shall be in writing and shall state the reasons or basis for the decision. Copies of the decision shall be served on the parties. The decision shall be issued not more than 15 days after the challenge is docketed under §801.305. The record, including the decision, shall be certified as true and complete by the hearing officer and forwarded to the Examiner (State Supervisor), U.S. Office of Personnel Management in the State involved at the address set out in appendix C to this part. It shall be available to interested persons at that office. When a hearing officer sustains a challenge, he shall, after the courts have finally sustained his decision or the time for petitioning for a court review of that decision has expired, instruct an examiner to remove the name of the challenged person from the eligibility list and cancel that person's certificate evidencing his eligibility to vote. The examiner shall notify the challenged person, the appropriate election official, the Attorney General, and the attorney general of the appropriate State of his action. There is no administrative appeal from the decision of a hearing officer or from any of his rulings. A petition for review of the decision of a hearing officer may be filed in court as provided in the Act. The subpart prescribes the bases and procedures for removals from eligibility lists under the Act. An examiner shall remove the name of a person from an eligibility list: (a) Pursuant to the instruction of a hearing officer under §801.316; (b) Pursuant to the order of a court having jurisdiction under the Act; (c) When the examiner determines that the listed person has lost his eligibility to vote under State law not inconsistent with the Constitution and the laws of the United States and in accordance with the instructions concerning loss of eligibility to vote prescribed by the OPM after consultation with the Attorney General which shall be set out in appendix D to this part and incorporated in and made a part of this section. An examiner may remove the name of a listed person as authorized by §801.402(c) only after: (a) Giving the person a notice of the proposed removal of his name stating the reason why the removal is proposed and offering the person an opportunity to answer the notice of proposed removal in person or in writing or both within ten days after his receipt of that notice; and (b) Considering all available evidence concerning the person's loss of eligibility to vote, including any timely answer submitted by the person. When an examiner removes the name of a person from an eligibility list he shall notify the person, the appropriate election officials, the Attorney General, and the attorney general of the State of that removal and the reason therefor. This subpart prescribes the procedure for filing and processing a complaint under the Act that a person was not permitted to vote. A person who has been listed on an eligibility list or registered by an appropriate election official and who is eligible to vote but has not been permitted to vote may make a complaint regarding that denial to an examiner for the political subdivision where the denial occurred. The complaint may be either oral or in writing and must be made within 48 hours after the closing of the polls. The examiner to whom a complaint is made shall promptly ascertain whether the complaint is well founded. If the examiner determines the complaint is not well founded he shall notify the person who complained of his determination and take no further action on the complaint. If the examiner determines that the complaint is well founded the examiner shall notify the person and the Attorney General of his determination and of the reason for that determination and furnish the Attorney General with any papers or evidence relating to the complaint. This appendix sets out the dates, times, and places designated by the OPM for filing an application in each political subdivision, and sets out the forms of application prescribed by the OPM. Dates, Times, and Places for Filing Offices at which applications may be filed will be open in each State in the county or parish and at the place set forth in this appendix beginning on the date specified and continuing thereafter until a closing date is given. Each office will be open Monday through Saturday (except on a legal holiday) between the hours of 8:30 a.m. and 4:30 p.m., except that the OPM may change the hours and days on which any office will be open for filing applications by posting advance notice of the change at the place set forth in this appendix. Alabama County; Place for filing; Beginning date Autauga; (1) Prattville—U.S. Post Office; November 8, 1965; (2) Marbury—building adjacent to U.S. Post Office, intersection of Main Street and State Highway 143; February 26, 1966. Barbour; Holiday Inn, Room 101, Barbour St. at Riverside Drive, Eufaula, Alabama, 36027, (205) 687–7903. Bullock; Union Springs—U.S. Post Office, 108 E. Hardaway Street; November 7, 1978. Chambers; Lafayette—Examiners Office, Room 218, FHA Office, County Building, 18 Alabama Avenue E.; July 30, 1984. Choctaw; Butler—Post Office; May 31, 1966. Conecuh; Evergreen—Holiday Inn, Room 108, Interstate 68 and Highway 83; September 2, 1980. Dallas; (1) Selma—Federal Building; August 10, 1965; (2) Orrville—U.S. Post Office, State Highway 22; February 26, 1966. Elmore; (1) Wetumpka—U.S. Post Office; November 8, 1965; (2) Eclectic—trailer at U.S. Post Office; February 26, 1966; (3) Elmore—trailer at U.S. Post Office; February 26, 1966. Greene; (1) Eutaw—U.S. Post Office; November 8, 1965; (2) Boligee—trailer at U.S. Post Office; March 8, 1966. Grenada; Grenada—Post Office Building; July 22, 1966. Hale; (1) Greensboro—Post Office Building; August 10, 1965; (2) Moundville—Tidmore Building; February 26, 1966. Jefferson; (1) Bessemer—Post Office Building, North 19th Street, January 24, 1966; (2) Birmingham—Post Office and Courthouse Building, 18th at 5th Avenue, North; January 24, 1966; (3) Fairfield—4412 Gary Avenue; January 24, 1966; (4) North Birmingham—Post Office Building; 2003 41st Avenue (Sayreton), Birmingham; February 14, 1966; (5) Powderly—Library Building, Birmingham Baptist College, 630 Ishkooda Road, Birmingham; February 14, 1966; (6) Wylam—trailer at Post Office, 4221 7th Avenue (Wylam), Birmingham; February 21, 1966; (7) Irondale—7949–A Crestwood Boulevard; February 26, 1966; (8) Homewood—1820 28th Avenue; February 26, 1966; (9) Tarant—1322 Main Street; March 18, 1966. Lowndes; (1) Fort Deposit—Post Office Building; August 10, 1965; (2) Hayneville—trailer at U.S. Post Office; January 3, 1966. Madison; (1) Canton—285 Peace Street; August 10, 1965; (2) Flora—Segrist Building opposite post office; July 20, 1966. Marengo; (1) Demopolis—Post Office Building; August 10, 1965; (2) Putnam—trailer adjacent to Post Office; State Highway 69; March 18, 1966. Monroe; Room 112, Monroe Motor Court South, Highway 21, Monroeville, Alabama. August 31, 1984. Montgomery; (1) Montgomery—Post Office and Courthouse Building, corner of Church, Lee, and Moulton Streets, Rooms 332, 334, 336; October 6, 1965, to November 6, 1969; (2) Montgomery—Aronov Building, 474 South Court Street, Room 132; November 7, 1969; (3) Mount Meigs—trailer at U.S. Post Office, intersection of U.S. Highway 80 and Pike Road; February 26, 1966. Perry; (1) Marion—Post Office Building, Room 3; August 20, 1965; (2) Uniontown—trailer at corner of West and Front Streets; March 5, 1966. Pickens; Carrollton—U.S. Post Office, Room 200, Courthouse Square, Highway 86; September 5, 1978. Russell; Phoenix City—U.S. Post Office, 1310 Ninth Avenue; September 26, 1978. Sumter; Livingston—Post Office; May 3, 1966. Wilcox; (1) Camden—Federal Building, Room 202–204; August 20, 1965; (2) Alberta—trailer at intersection of State Highway 5 and County Highway 29; March 5, 1966; (3) Pine Apple—trailer at U.S. Post Office, County Highway 59; March 5, 1966. Arizona County; Place for filing; Beginning date. Apache; Window Rock Motor Inn, P.O. Box 1687, Window Rock, Arizona; October 31, 1986. Navajo; Holiday Inn, P.O. Box 307, Kayenta, Arizona; October 31, 1986. Yuma; U.S. Border Station, Highway 95, International Borderline, San Luis, Arizona, 85349; (602) 627–2016; February 26, 1991. California County; Place for filing; Beginning date Alameda; Oakland-U.S. Attorneys Office, Oakland Branch, 1301 Clay Street, Suite 3405, Oakland, California, 94612; (510) 637–3784 and (510) 637–3748; March 23, 1996. Georgia County; Place for filing; Beginning date Baker; Newton—U.S. Post Office Building; Nov. 5, 1968. Baldwin; ASCS, Post Office Building, 110 Handcock Street, Room 206, Milledgeville, Georgia; Sept. 21, 1984. Brooks; Georgian Motel, room 8, 803 East Screven Street, Quitman, GA 31643; (912) 263–9306 or 263–9307, July 17, 1990. Bulloch; Statesboro—Federal Building, Conference Room 208, 52 North Main Street; August 5, 1980. Burke; Waynesboro-U.S. Post Office, 721 Liberty Street, Room 204; November 2, 1982. Butts; (1) Jackson—Daughty Foundation, 221 College Street; September 4, 1982; (2) Flovilla—Flovilla Community Center, Collier Street; September 4, 1982; (3) Jenkinsburg—Cleveland BBQ Restaurant Building, Corner of Highway 42 and High Falls Road; September 4, 1982. Calhoun; Morgan—Soil Conservation Service, Main Street, P.O. Box 113; August 5, 1980. Chattahoochee; U.S. Post Office Lumpkin Highway, Cusseta, Georgia; Sept. 21, 1984. Early; Blakely—Qual Motel, Room 26, U.S. 27 South; August 5, 1980. Hancock; Sparta—Post Office Building, Broad Street; November 8, 1966. Jefferson; Post Office Building Room 4, 131 W. Broad Street, Louisville, Georgia; Sept. 21, 1984. Johnson; Wrightsville—U.S. Post Office, Basement Office 1, 151 South Marcus; August 5, 1980. Lee; (1) Leesburg—Farmers Exchange Building, Second Floor; April 3, 1967, through April 30, 1969; (2) Leesburg—U.S. Post Office, intersection of State Highway 32 and U.S. Highway 19; May 1, 1969. McIntosh; Best Western, Swiss Inn, room 115, Highway 251 and Interstate 95, Darien, Georgia 31304; (912) 437–4418 or 4421; July 21, 1992. Meriweather; Greenville—U.S. Department of Agriculture, Agricultural Stabilization Conservation Service Office, Williams Street; August 10, 1976. Mitchell; Camilla—FHA District Office Conference Room, Building 10A, Broad Street; August 5, 1980. Peach; Fort Valley—U.S. Post Office Building; 300 West Church Street; November 7, 1972. Pike; ASCS, Pike County Agriculture Building, Gwyn Street, Zebulon, Georgia; Sept. 21, 1984. Randolph, Travelers Mini Lodge, Room 2, 949 Blakely Street, Cuthbert, Georgia, 31740; (912) 732–5806 or 5807; August 11, 1992. Screven; Sylvania—Post Office Building, Main and East Telephone Streets; April 3, 1967. Stewart; Lumpkin—U.S. Department of Agriculture, Agricultural Stabilization Conservation Service Office, Meeting Room, Court House, Second Floor; August 10, 1976. Sumter; Americus—Federal Building and Court House, Basement Conference Room 128, East Forsyth Street; August 5, 1980. Talbot—Buice Motel, Room 2, Washington St., Talbotton, Georgia 31827, August 9, 1988. Taliaferro; Crawfordville—Post Office; November 5, 1968. Telfair; McRae—Postmasters Office, U.S. Post Office, 211 South Second Avenue; August 5, 1980. Terrell; Dawson—Post Office Building, Stonewall and Lee Streets; April 3, 1967. Tift; Tifton—FHA, Conference Room 306, Tifton County Administrative Building, 225 Tift Avenue; August 5, 1980. Twiggs; Jeffersonville—County Office Building; State Highway 96; September 3, 1974. Worth; ASCS, Worth County ASCS Building, 501 N. Henderson, Sylvester, Georgia; Sept. 21, 1984. Louisiana Parish; Place for filing; Beginning date Bossier; (1) Benton—trailer at Post Office; April 3, 1967; (2) Bossier City—Lodge Hall, 1708 Scott Street; April 5, 1967 through March 17, 1969; (3) Bossier City—Post Office, 150 Benton Road, March 18, 1969. Caddo; (1) Shreveport—Post Office and Courthouse Building, 424 Texas Street; April 3, 1967; (2) Shreveport—Terry Building, 2643 Cooper Road; April 3, 1967; (3) Shreveport; Hollywood Baptist Church; 5305 Roberts Street; April 3, 1967. De Soto; Mansfield—trailer, at Post Office; April 3, 1967. East Carroll; (1) Lake Providence—Post Office Building; August 10, 1965; (2) Sondheimer—trailer at Post Office Building; February 14, 1966; (3) Lake Providence—ASCS Office, 205 North Hood; October 19, 1979. East Feliciana; (1) Clinton—Kline Building, St. Helena Street; August 10, 1965, to February 8, 1966; (2) Clinton—Trailer at U.S. Post Office; February 19, 1966; (3) Jackson—Trailer parked on Post Office grounds; February 14, 1966; (4) Slaughter—Post Office Building; February 14, 1966. Madison; Tallulah—Post Office; August 13, 1966. Ouachita; (1) Monroe—Post Office Building, Room 301; August 20, 1965; (2) West Monroe—I. B. Haynes Building, Cypress and Young Streets, February 14, 1966. Plaquemines; (1) Buras—Post Office Building, August 10, 1965, through November 17, 1965, reopened August 31, 1967; (2) Belle Chasse—Post Office Building; November 18, 1965; (3) Belle Chasse—US Naval Air Station, Administration Building, Room 46, Office of the Senior Chief of Command; October 19, 1979. Sabine; Many—U.S. Post Office Building; 525 San Antonia Avenue; September 27, 1974. St. Helena; Greensburg—(1) Trailer at Post Office; College and Main Streets; August 19, 1972; (2) ASCS Office, Burrell Carter Building, Street Floor, South Main Street; October 19, 1979. St. Landry; Opelousas—Chattau Motor Inn, 400 East Landry, the Bayou Room; December 5, 1979. West Feliciana; (1) Saint Francisville—trailer at Post Office; November 3, 1965, through January 7, 1966; (2) Saint Francisville—Post Office Building; January 8, 1966; (3) Weyanoke—trailer located on State Highway 66 approximately 0.3 mile South of Weyanoke; February 14, 1966. Mississippi County; Place for filing; Beginning date Adams; Prentiss Inn, U.S. 61 S, Natchez, Mississippi 39121; (601) 442–7524/25; September 17, 1991. Amite; (1) Liberty—Walsh Building, Main Street, second floor; April 3, 1967; (2) Gloster—Ivey Building, First Street; July 29, 1967. Benton; Ashland—Post Office Building; October 1, 1965. Bolivar; Cleveland—Post Office Building; October 1, 1965. Carroll; (1) Carrollton—Post Office Building, Main Street, January 4, 1966, through March 22, 1968; (2) North Carollton—Van Meter Lumber Co. Building, George Street, March 23, 1968. Chickasaw; U.S. Office of Personnel Management, 75 Spring Street SW, Room 905, Atlanta, Georgia, 30303; 1 (888) 496–9455; August 3, 1999. Claiborne; (1) Port Gibson—McFatters Drug Store, Second Floor, 618 Main Street; April 16, 1966, through October 9, 1969; (2) Port Gibson—Federal Building, Room 111; October 10, 1969. Clay; (1) West Point—Post Office Building; October 1, 1965; (2) Pheba—rear of Champion Grocery Store; July 21, 1967. Coahoma; Clarksdale—Post Office Building; October 1, 1965. Copiah; Hazelhurst—W.S. Henley Building, 122 South Lowe Street; December 13, 1983. Covington; Collins—McLauren Building, FHA Conference Room; August 10, 1979. De Soto; (1) Walls—U.S. Post Office; November 8, 1965, through January 4, 1966; (2) Hernando—U.S. Post Office; January 5, 1966; (3) Olive Branch—second floor above Post Office; July 22, 1967. Forrest; (1) Hattiesburg—U.S. Courthouse, corner of Pine and Forrest Streets, Room 6; June 8, 1967; (2) Petal—108 Ninth Avenue; September 16, 1967. Franklin; Meadville—Old Halford Building, Highway 84 East, one block from city square; April 3, 1967. Greene; Leakesville—FHA Conference Room, New Bank Annex, Main and Lafayette Street; August 10, 1979. Grenada; (1) Grenada—Post Office Building; July 22, 1966, through August 7, 1966; (2) Grenada—639 Union Street; August 8, 1966, through October 9, 1969; (3) Grenada—U.S. Post Office, basement, October 10, 1969; (4) Tie Plant—trailer at site of Horseshoe Store two blocks west of Tie Plant School on dirt road; September 9, 1966. Hinds; (1) Jackson—301 Building, 301 North Lamar Street; November 8, 1965, through January 2, 1966; (2) Jackson—Post Office Building, 245 East Capitol Street; January 3, 1966; (3) Jackson—848 Lynch Street; June 22, 1966; (4) Raymond—U.S. Post Office; November 8, 1965. Holmes; (1) Lexington—U.S. Post Office; November 8, 1965; (2) Cruger—U.S. Post Office; July 29, 1967. Humphreys; (1) Belzoni—Post Office Building; October 1, 1965; (2) Louise—Post Office Building; June 21, 1966; (3) Isola—trailer at Post Office, August 23, 1971. Issaquena; Mayersville—trailer at Post Office; June 15, 1967. Jasper; Bay Springs—trailer at New Post Office; April 16, 1966. Jefferson; Fayette—Ball Drug Store Building, Main Street; November 8, 1965. Jefferson Davis; (1) Prentiss—Magnolia Courts, intersection of U.S. Highway 84 and State Highway 42, Units 21 through 24; August 25, 1965, through August 26, 1965; (2) Prentiss—Post Office Building; August 27, 1965. Jones; (1) Laurel—Federal Building, Room B–8; August 20, 1965; (2) Ellisville—102 Jasmine Street; September 16, 1967. Kemper; DeKalb—U.S. Post Office; Lobby; Seventh Street and Eighth Avenue; November 4, 1974. Leake; U.S. Office of Personnel Management, 75 Spring Street SW, Room 905, Atlanta, Georgia 30303; 1 (888) 496–9455; August 3, 1999. Leflore; (1) Greenwood—Post Office Building; August 10, 1965; (2) Minter City—trailer on lot on northwest side of Post Office; June 6, 1967. Lowndes; Columbus—Ramada Inn, Room 153, Highway 45 North; August 22, 1983. Madison; Canton—285 Peace Street; August 10, 1965. Marshall; Holly Springs—Post Office Building; August 8, 1967. Monroe; Sheliane Motel, Room 44, Highway 45 N, Aberdeen, Mississippi, 39730; (601) 369–2192/2193; September 17, 1991. Neshoba; Philadelphia—U.S. Post Office; November 8, 1965. Newton; (1) Newton—Post Office Building; January 4, 1966; (2) Decatur—building on Fourth Avenue across street from U.S. Post Office; July 29, 1967. Noxubee; (1) Macon—Post Office Building, Basement, Room 1; April 16, 1966; (2) Brooksville—Jourdan Building, Front Street; July 29, 1967. Oktibbeha; Starkville—Post Office Building, 302 University Drive; April 3, 1967. Pearl River; Picayune—Community Recreation Center; Library; Rosa and Beech Streets; June 8, 1974. Quitman; Marks—Corp of Engineers, Rogers Road; October 29, 1980. Rankin; (1) Brandon—Rankin Building, intersection of U.S. Highway 80 and State Highway 18; April 16, 1966, through August 4, 1966; (2) Brandon—Nettles Drug Store Building, East Government Street; August 5, 1966 through January 31, 1971; (3) Brandon—280 Government Street; February 1, 1971. Scott; Best Western, room 130, Interstate 20 and Highway 251, Forest, Mississippi, 39074; (601) 469–4031 or 3950; May 18, 1993. Sharkey; Rolling Fork—102 Elm Street; June 14, 1967. Simpson; (1) Mendenhall—Post Office Building; January 4, 1966; (2) Magee—Post Office Building, Ninth Avenue (between Eighth and Ninth Streets); January 10, 1966. Sunflower; (1) Indianola—Post Office Building; May 2, 1967; (2) Ruleville—U.S. Post Office, 120 South Ruby Avenue; June 16, 1983. Tallahatchie; (1) Charleston—103 Market Street; August 23, 1971; (2) Sumner—Abbey Building, East Court Square; August 23, 1971. Tunica; Tunica—Department of Agriculture Building, Agricultural Conservation and Stabilization Service; South Side, Court Square; November 3, 1975. Warren; Vicksburg—Post Office and Courthouse Building, Crawford and Monroe Streets; January 4, 1966. Washington; Greenville—Room 204A Federal Building, Main Street and Poplar Street; August 8, 1983. Wilkinson; (1) Woodville—Post Office Building; August 8, 1967, to August 24, 1967; (2) Woodville—Odd Fellows Building; August 24, 1967. Winston; Louisville—Post Office Building; Basement, Room 6; April 16, 1966. Yazoo; Yazoo City, 100 South Main Street; November 2, 1971. New Mexico County; Place for filing; Beginning date. Chavez; Federal Building, 5th and Richardson Street, Roswell, New Mexico; December 17, 1984. Cibola; U.S. Forest Service, Mt. Taylor Ranger District, Cibola National Forest, 201 Roosevelt, Grants, New Mexico; December 17, 1984. Curry; Main Post Office, 417 Gidding, Room 203, Clovis, New Mexico; December 17, 1984. McKinley; Bureau of Indian Affairs, Eastern Navajo Agency, P.O. Box 328, Crowpoint, New Mexico (25 miles north of Thoreau, 1 mile west of State Road 57); Bureau of Indian Affairs, Navajo Area Office, Federal Building, 3rd and Hill Streets, Gallup, New Mexico; December 17, 1984. Otero; U.S. Forest Service, Lincoln National Forest, Federal Building, 11th and New York Streets, Alamogordo, New Mexico; December 17, 1984. Sandoval; Mobile unit on parking lot behind U.S. Post Office, Camino del Pueblo Road, Bernalillo, New Mexico; U.S. Forest Service, Cuba Ranger District, San Fe National Forest, State Highway 126 and South Main, Cuba, New Mexico. December 17, 1984. New York County; Place for filing; Beginning date Bronx, Kings, and New York Counties, New York; 26 Federal Plaza, Room 29108, New York, New York. North Carolina County; Place for filing; Beginning date Edgecombe; Tarboro—Room B3, U.S. Post Office, 525 Main Street, Tarboro, North Carolina; May 4, 1984. South Carolina County; Place for filing; Beginning date Bamberg; Room 6, Farmers Home Administration, J. Carl Kershe Agriculture Building, Calhoun Street, Bamberg, South Carolina. October 10, 1984. Calhoun; Room 5, 2nd Floor, 111 Harry C. Raysor Drive, St. Mathews, South Carolina. September 28, 1984. Chester; Chester Motor Lodge, Room 161, West End St. at By-pass, Chester, SC 29706, (803) 385–5511. Clarendon; Manning—Federal Building; November 8, 1965. Colleton; Soil Conservation Service, Room 203, 119 Benson Street, Walterboro, South Carolina. October 10, 1984. Darlington; Darlington—U.S. Post Office, 201 Pearl Street; November 7, 1978. Dorchester; St. George—U.S. Post Office; November 8, 1965. Hampton; Farmers Home Administration, 1st Floor, 1003 Elm Street, Hampton, South Carolina. October 10, 1984. Marion; Marion—U.S. Post Office, 201 South Main Street, Conference Room; June 27, 1978. Richland; Room 1466, Strom Thurmond FOB, 1835 Assembly Street, Columbia, South Carolina. September 28, 1984. Williamsburg; ASCS Service Center, 208 Short Street, Kingstree, South Carolina. September 28, 1984. Texas County; Place for filing; Beginning date Atascosa; Pleasanton—Office of USDA, 803 North Bryant; October 29, 1980. Bee; Beeville—Agriculture Plant and Animal Inspection Service; Basement, U.S. Post Office, 111 N. St. Mary's Street; November 2, 1976. Crockett; Ozona—Agricultural Stabilization and Conservation Office, 801 Avenue E; August 12, 1978. Dallas; Dallas—OPM, Room 6B3, 1100 Commerce Street, Dallas, Texas, April 4, 1984. El Paso; El Paso—2211 East Missouri Avenue, Suite N300; November 7, 1978. Fort Bend; Richmond—Agricultural Stabilization Conservation Office; May 1, 1976. Frio; Pearsall—Federal Building, 411 East Colorado Avenue; November 2, 1976. Galveston; 5914 Seawall Boulevard, Galveston, Texas 77551, (409) 740–1261; December 9, 1996. Hidalgo—101 East 14th (West Entrance), Mission, Texas, 78572, (512) 585–8380, November 8, 1988. Jefferson; 1610 I–10 South, Beaumont, Texas 77707, (409) 842–0037; December 9, 1996. La Salle; Cotulla—U.S. Border Patrol Station, Federal Building, North Main Street; November 2, 1976. Medina; Hondo—Agricultural Stabilization Conservation Office; 1703 Avenue K; May 1, 1976. Reeves; Pecos—U.S. Post Office, U.S. Attorneys Office, Room 301; May 6, 1978. Uvalde; Uvalde—Agricultural Stabilization Conservation Office; 119 West South Street; May 1, 1976. Wilson; Floresville—Agricultural Stabilization Conservation Office; May 1, 1976. Forms of Application alabama Front Application To Be Listed Under the Voting Rights Act of 1966 Instructions to the Applicant: Please fill out this side of this form. If you need help in answering any question, the Examiner will help you. 1. Name _______ (First) _______ (Middle) _______ (Last) 2. Age _____ 3. Address ______ (RFD or Street Number) _____ (Street) _____ (City or Town) _____ (State) 4. How long have you lived in Alabama? 6. What is your precinct? ___ or ward? ___ 7. Are you now (1) on active duty in the Armed Forces of the United States or the Alabama National Guard, (2) an employee of the United States or the State of Alabama, or (3) a seaman or college student? ___ o Yes o No 8. (a) Are you now registered to vote in Alabama? ___ o Yes o No (b) Are you now listed under the Voting Rights Act? ___ o Yes o No 9. Are you a citizen of the United States and of the State of Alabama? ___ o Yes o No 10. Have you ever been convicted of a crime other than a traffic violation? ____ o Yes o No 11. Have you ever been declared legally insane by a court? ___ o Yes o No Any willful false statement on this application is a Federal crime punishable by fine or imprisonment. Stop Here. Take the Form to the Examiner I do solemnly swear (or affirm) that the information I have provided is true and correct to the best of my knowledge, information, and belief. I do further personally swear (or affirm) that I will support and defend the Constitution of the United States and the Constitution of the State of Alabama; and that I do not believe in nor am I affiliated with any group or party which advocated or advocates the overthrow of the Government of the United States or of the State of Alabama by unlawful means. Back Do not write on this side—for use by examiner Additional Information Items 4. If applicant shows that he has not lived in Alabama for one year, will he have lived in Alabama for one year by the date of the next election? ___ o Yes o No __________ 5. If applicant shows that he has not lived at his present address for six months, will he by the date of the next election have: Lived in the same county for six months? ___ o Yes o No __________ Lived in his precinct or ward for three months? ___ o Yes o No __________ Lived in the same city or town for three months? ___ o Yes o No __________ 7. If applicant answers yes, is his residence in Alabama and in his county for temporary purposes only? ___ o Yes o No (b) If applicant shows that he is now listed under the Voting Rights Act, write in the county where he is listed ______ and certificate number if available ______. 10. If applicant answers yes, name the crime __________ Where and when convicted? __________ Was the conviction for a disqualifying crime? ____ o Yes o No If a disqualifying crime, has applicant been pardoned with restoration of his right to vote? ___ o Yes o No 11. If applicant answers yes, has he subsequently been declared legally sane or competent by a court? ___ o Yes o No Certificate of Eligibility Issued-No. _____ Notification of Ineligibility Issue-No. _____ georgia Front Application To Be Listed Under the Voting Rights Act of 1965 Instructions to the Applicant: Please fill out this side of this form. If you need help in answering any question, the Examiner will help you. 1. Name _______ (First) _______ (Middle) _______ (Last) 2. Age _____ 3. Address ______ (RFD or Street Number) _____ (Street) _____ (City or Town) _____ (State) 7. Are you now on active duty in the Armed Forces of the United States? ____ o Yes o No 8. (a) Are you now registered to vote in Georgia? ___ o Yes o No (b) Are you now listed under the Voting Rights Act? ___ o Yes o No 9. Are you a citizen of the United States and of the State of Georgia? ___ o Yes o No 10. Have you ever been convicted of a crime other than a traffic violation? ____ o Yes o No 11. Have you ever been declared legally insane or idiotic by a court? ___ o Yes o No Any willful false statement on this application is a Federal crime punishable by fine or imprisonment. Stop Here. Take the Form to the Examiner I do solemnly swear (or affirm) that I am not registered to vote under any other name; that I have correctly answered the questions appearing elsewhere on this application; that the information contained elsewhere on this application is true. Back Do not write on this side—for use by the Examiner Additional Information Items 2. If applicant shows his age to be under 18, will he be 18 by the date of the next election? ___ o Yes o No 4. If applicant shows that he has not lived in Georgia for one year, will he have lived in Georgia for one year by the date of the next election? ___ o Yes o No __________ 5. If applicant shows that he has not lived at his present address for six months, will he have lived within the same county for six months by the date of the next election? ___ o Yes o No __________ 7. If applicant answers yes, is his residence in Georgia and in his county for temporary purposes only? ___ o Yes o No 10. If applicant answers yes, name the crime __________ Where and when convicted? __________ Was the conviction for a disqualifying crime? ____ o Yes o No If a disqualifying crime, has applicant been pardoned? ___o Yes o No 11. If applicant answers yes, has he subsequently been declared legally sane or competent by a court? ___ o Yes o No louisiana Front Application To Be Listed Under the Voting Rights Act of 1965 Instructions to the applicant: Please fill out this side of this form. If you need help in answering questions 1 through 13, the Examiner will help you. 1. Name _______ (First) _______ (Middle) _______ (Last) 2. Age _____ 3. Address ______ (RFD or Street Number) _____ (Street) _____ (City or Town) _____ (State) 7. Are you now (1) on active duty in the Armed Forces of the United States or the Louisiana National Guard, (2) an employee of the United States or the State of Louisiana, or (3) a seaman or college student? ___ o Yes o No 8. (a) Are you now registered to vote in Louisiana? ___ o Yes o No (b) Are you now listed under the Voting Rights Act? ___ o Yes o No 9. Are you a citizen of the United States and of the State of Louisiana? ___ o Yes o No 10. Have you ever been convicted of a crime other than a traffic or game violation? ___ o Yes o No 11. Have you ever been dishonorably discharged from or are you a deserter from the Louisiana National Guard or militia or the military service of the United States? ___ o Yes o No 12. Have you ever been declared legally insane or incompetent by a court? _____ o Yes o No 13. Are you now living in a charitable home or institution? ___ o Yes o No Any willful false statement on this application is a Federal crime punishable by fine or imprisonment. Stop Here. Take the Form to the Examiner I do solemnly swear (or affirm) that I will faithfully and fully abide by all of the laws of the State of Louisiana, that I am well disposed to the good order and happiness of the State of Louisiana and of the United States, and that the information I have provided is true to the best of my knowledge and belief. Back Do not write on this side—For use by examiner Additional Information Items 2. If the applicant shows his age to be under 21, will he be 21 by the date of the next election? ___ o Yes o No 4. If the applicant shows that he has not lived in Louisiana for one year, will he have lived in Louisiana for one year by the date of the next election? ___ o Yes o No __________ 5. If applicant shows that he has not lived at his present address for six months, will he by the date of the next election have: Lived in the same parish for six months? ___ o Yes o No __________ Lived in this precinct for three months? ___ o Yes o No __________ Lived in the same town or city for four months? ___ o Yes o No __________ 7. If applicant's answer is yes, is his residence in Louisiana and in his parish for temporary purposes only? ___ oYes o No Was the conviction for a disqualifying crime? ____ o Yes o No If a disqualifying crime, has applicant been pardoned with express restoration of the right to vote? ___ o Yes o No If dishonorably discharged, has he been reinstated? ___ o Yes o No If a deserter, has he returned to his command and made up his lost time? _____ o Yes o No 12. If applicant shows that he has been declared legally insane or incompetent by a court, has he subsequently been declared legally sane or competent by a court? ____ o Yes o No 13. If the applicant shows that he is now living in a charitable home or institution, is he disqualified? ___ o Yes o No mississippi Front Application to be Listed Under the Voting Rights Act of 1965 Instructions to the Applicant: Please fill out both sides of this form. If you need help in answering any question, the Examiner will help you. 1. Name _______ (First) _______ (Middle) _______ (Last) 4. Are you a citizen of the United States? ___ o Yes o No 5. What is your present residence address and each place you have resided during the past year, stating when you lived at each place? (a) Present address __________ From ______ to date. (b) Previous address __________ From ______ to ______ (c) Previous address __________ From ______ to ______ (If you need additional space, use the back side of this form.) 6. What is your election district? ______ Beat _______ Precinct _______ City Ward _____ 7. Are you now registered to vote in Mississippi? ___ o Yes o No 8. Have you ever been convicted of a crime of murder, rape, bribery, theft, arson, obtaining money or goods under false pretenses, perjury, forgery, embezzlement or bigamy? ___ o Yes o No Has the right to vote been restored? ___ o Yes o No 9. Have you ever been declared legally insane by a court? ___ o Yes o No 11. Do you intend to make this precinct and county your fixed habitation, for a definite or indefinite length of time, to which you intend to return whenever absent? ___ o Yes o No Any willful false statement on this application is a Federal crime punishable by fine or imprisonment. Stop Here. Take the Form to the Examiner I do solemnly swear (or affirm) that I am at least eighteen (18) years old (or will be before the next election in this county), and that I am now in good faith a resident of this state and of __________ election precinct in this county and that I am not disqualified from voting by reason of having been convicted of any crime named in the Constitution of this state as a disqualification to be an elector; that I have truly answered all questions propounded to me in the foregoing application for registration; and that I will faithfully support the Constitution of the United States and of the State of Mississippi, and will bear true faith and allegiance to the same. So help me God. Back Do not write on this side—for use by examiner Additional Information Items 2. If applicant shows his age to be under 21, will he be 21 by the date of the next election? ___ o Yes o No 5. If applicant shows that he has not lived in Mississippi for two years, will he have lived in Mississippi for two years by the date of the next election? ___ o Yes o No __________ 6. If applicant shows that he has not lived at his present address one year, will he by the date of the next election have: Lived in the same election district for one year? ___ o Yes o No If applicant is a minister or minister's wife, for 6 months? ___ o Yes o No __________ Lived in the same city, town, or village for one year? ___ o Yes o No If applicant is a minister or minister's wife, for 6 months? ___ o Yes o No __________ 10. If applicant answers yes, was the conviction for bribery, burglary, theft, arson, perjury, forgery, embezzlement, bigamy, or obtaining money or goods under false pretenses? ___ o Yes o No If yes, answer the following questions: 11. If applicant answers yes, has he subsequently been declared legally sane or competent by a court? ___ o Yes o No south carolina Front Application To Be Listed Under the Voting Rights Act of 1965 Instructions to the Applicant: Please fill out this side of this form. If you need help in answering any question, the Examiner will help you. 1. Name _______ (First) _______ (Middle) _______ (Last) 2. Age _____ 3. Address ______ (RFD or street number) _____ (Street) _____ (City or town) _____ (State) 4. (a) Are you a minister in charge of an organized church or the spouse of such a minister ___ o Yes o No (b) Are you a teacher in a public school or the spouse of such a teacher ___ o Yes o No 8. Are you now (1) a student, (2) a seaman, (3) an employee of the United States, or (4) on active duty in the Armed Forces of the United States ___ o Yes o No 9. (a) Are you now registered to vote in South Carolina ___ o Yes o No (b) Are you now listed under the Voting Rights Act ___ o Yes o No 10. Are you a citizen of the United States and the State of South Carolina ____ o Yes o No 11. Have you ever been convicted of a crime other than a traffic violation ____ o Yes o No 12. Have you ever been declared legally insane, idiotic, or mentally incompetent by a court ___ o Yes o No 13. Are you a pauper receiving all your support from your county, town, or city government ___ o Yes o No Any willful false statement on this application is a Federal crime punishable by fine or imprisonment Stop Here—Take the Form to the Examiner I hereby solemnly swear (or affirm) that the information I have provided is true to the best of my knowledge and belief and I so certify. CSC Form 805–S, October 1965 Back Do not write on this side—for use by examiner Additional Information Items 5. If the applicant shows that he has not lived in South Carolina for one year, will he have lived in South Carolina for one year by the next election (or six months if applicant is a minister in charge of an organized church or a teacher in a public school, or the spouse of either) ___ o Yes o No 6. If the applicant (other than a minister, teacher, or spouse of either) shows that he has not lived at the same address for six months, will he by the date of the next election have: Lived in the same county for six months ___ o Yes o No Lived in the same city or town for four months ___ o Yes o No Lived in the same precinct for three months ___ o Yes o No 8. If applicant answers yes, is his residence in South Carolina and in his county for temporary purposes o Yes o No Was the conviction for a disqualifying crime ___ o Yes o No If a disqualifying crime, has the disqualification been removed by pardon of the Governor ___ o Yes o No 12. If the applicant shows that he has been declared legally insane, idiotic, or mentally incompetent by a court, has he subsequently been declared legally sane or mentally competent by a court ___ o Yes o No texas Front Voting Rights Act Application The information requested below is for the purpose of determining whether you are eligible to vote. If you are found eligible to vote, your name will be certified to appropriate state officials for addition to the official voting lists. The solicitation of this information for this purpose is authorized by the Voting Rights Act of 1965, as amended. While you are not required to respond, your cooperation is needed if you wish to be found eligible to vote. Instructions to the Applicant: Please fill out this side of this form. If you need help in answering any question, the Examiner will help you. 1. Name _______ (First) _______ (Middle) _____ (Last) Maiden surname if married woman: _____ 2. Sex: _____ 3. Permanent residence address: __________ (Street and Apt. No., if any, or Route No. or location (Not P.O. Box)) _______ (City) _____ (ZIP code) 5. Mailing address if different from above: __________ (Street or P.O. box) _____ (City) _____ (State) _____ (ZIP code) 6. Birthplace: City _____ or county _____ State _____ or foreign country _____ 8. Former registration: If now registered in another Texas County: __________ (Name of county) Last residence address: __________ (Street and apt. No., if any) _____ (City) _____ (State) _____ (ZIP code) The disclosure of social security number and telephone number is voluntary. Failure to state either or both numbers will NOT result in your application being deficient. The numbers will be used only to maintain the accuracy and integrity of the registration records. Social Security Number _____ Telephone Number _____ Any willful false statement on this application is a Federal crime punishable by fine or imprisonment. STOP HERE. TAKE THE FORM TO THE EXAMINER. I do solemnly swear (or affirm) that I, the applicant, am 18 years of age or over, or will be 18 years of age or older within 60 days after applying for registration, and am a citizen of the United States, hold legal residence in this county, have met all legal requirements, and I understand that the giving of false information to procure the registration of a voter is a felony. *Agent must be a registered voter, and must be only: (Circle one applicable) Husband—Wife—Mother—Father—Son—Daughter Back Do not write on this side—For use by examiner Additional Information Items Texas law states that a person convicted of a felony and not subsequently pardoned, and a person adjudicated a lunatic or idiot and not subsequently adjudicated competent, are not qualified to vote. Therefore, the following questions must be asked. A. Have you ever been convicted of a felony: ___ o Yes o No Was the conviction for a disqualifying crime: ___ o Yes o No If a disqualifying crime, has applicant been pardoned with restoration of his right to vote: ___ o Yes o No B. Have you ever been declared to be an idiot or a lunatic by a court: ___ o Yes o No If applicant answers yes, has he subsequently been declared legally sane or competent by a court: ___ o Yes o No (5 U.S.C. 1103; Secs. 7, 9, 79 Stat. 440, 411, 441 (42 U.S.C. 1973c, 1973g)) [30 FR 9859, Aug. 7, 1965] Editorial Note: For This appendix sets out the qualifications required for listing on an eligibility list. alabama A person is qualified to be listed as an eligible voter in elections in the State of Alabama, except municipal elections, if he has all the following qualifications at the time he applies for listing and if he takes the required oath or affirmation. (1) He is 21 years of age. (2) He is a citizen of the United States and of the State of Alabama. (3) He will have lived in the State of Alabama for one year, in his county for six months, and in his ward or precinct for three months by the date of the next election. (4) He has not been convicted of treason, murder, arson, embezzlement, malfeasance in office, larceny, receiving stolen property, obtaining property or money under false pretenses, perjury, subornation of perjury, robbery, assault with intent to rob, burglary, forgery, bribery, assault and battery on the wife, bigamy, living in adultery, sodomy, incest, rape, crime against nature, or any crime punishable by imprisonment in the penitentiary, or of any infamous crime or crime involving moral turpitude, or of vagrancy or being a tramp, or of selling or offering to sell his vote or the vote of another, or of buying or offering to buy the vote of another, or of making or offering to make a false return in any election by the people or in any primary election to procure the nomination or election of any person to any office, or of suborning any witness or registrar to secure the registration of any person as an elector, or if so convicted he has been subsequently pardoned with restoration of his right to vote specifically expressed in the pardon. (5) He has not been declared legally insane by a court, or if so declared he has subsequently been declared legally sane or competent by a court. (6) He is not otherwise registered or listed as eligible to vote in the county in which he applies for listing. A person who has all the above qualifications is also qualified to be listed as an eligible voter in municipal elections if he will have lived in his city or town for three months by the date of the next election. georgia A person is qualified to be listed as an eligible voter in elections in the State of Georgia, except municipal elections, if he has all the following qualifications at the time he applies for listing and if he takes the required oath or affirmation. (1) He will be 18 years of age by the date of the next election. (2) He is a citizen of the United States and of the State of Georgia. (3) He will have lived in the State of Georgia for 1 year and in his county for 6 months by the date of the next election. (4) He has not been convicted of treason against the State, embezzlement of public funds, malfeasance in office, bribery or larceny, or of any crime involving moral turpitude, punishable by the laws of Georgia with imprisonment in the penitentiary, or if so convicted he has been subsequently pardoned. (5) He has not been declared legally insane or idiotic by a court, or if so declared he has been subsequently declared legally sane or competent by a court. (6) He is not otherwise registered or listed as eligible to vote in the county in which he applies for listing. louisiana A person is qualified to be listed as an eligible voter in elections in the State of Louisiana, except municipal elections, if he has all the following qualifications at the time he applies for listing and if he takes the required oath or affirmation. (1) He will be 21 years of age by the date of the next election. (2) He is a citizen of the United States and of the State of Louisiana. (3) He will have lived in the State of Louisiana for one year, in his parish for six months, and in his precinct for three months by the date of the next election. (4)(a) He has not been convicted of any crime punishable by imprisonment in the penitentiary, or if so convicted he has been subsequently pardoned with the express restoration of the franchise, or (b) he has not been convicted of a felony, or if so convicted he has subsequently received a pardon and full restoration of franchise. (5) He has not been interdicted, that is, declared legally incompetent or insane by a court, or if so interdicted he has been subsequently restored to legal competency or sanity by a court. (6) He has not been dishonorably discharged from the Louisiana National Guard or the military service of the United States, or if so discharged he has been reinstated. (7) He is not a deserter from the military services of the United States or the militia of the State of Louisiana, when called forth by the Governor or, in time of invasion, insurrection, or rebellion, by the President of the United States, or if such a deserter, he has returned to the command from which he deserted, made good the time lost in desertion, and served out the term of his original enlistment. (8) He is not an inmate of any charitable institution, except the Soldiers Home and the United States Marine hospital at Carville. (9) He is not otherwise registered or listed as eligible to vote in the parish in which he applies for listing. A person who has all the above qualifications is qualified to be listed as an eligible voter in municipal elections if he will have lived in his city or town for four months by the date of the next election. mississippi A person is qualified to be listed as an eligible voter in elections in the State of Mississippi, except municipal elections, if he has all the following qualifications at the time he applies for listing and takes the required oath or affirmation. (1) He will be 21 years of age by the date of the next election. (2) He is a citizen of the United States. (3) He will have lived in the State of Mississippi for two years by the date of the next election. (4) He will have lived in his election district or his city, town, village, or municipality for one year by the date of the next election. However, if the person is a minister or the wife of a minister of the Gospel in charge of an organized church, that person is qualified if he or she will have lived in the election district for six months by the date of the next election. (5) He has not been convicted of arson, bigamy, bribery, burglary, embezzlement, forgery, obtaining money or goods under false pretenses, perjury, or theft, or if so convicted his right to vote has been restored by the legislature. (6) He has not been declared legally insane by a court, or if so declared he has been subsequently declared legally sane or competent by a court. (7) He is not otherwise registered or listed as eligible to vote in the county in which he applies for listing. A person who has all the above qualifications is qualified to be listed as an eligible voter in municipal elections if he will have lived in his city, town, or village for one year by the date of the next election, unless he has, within two years before the next municipal election, been convicted within the municipality of violating the liquor laws of the State or the municipality. However, if the person is a minister or the wife of a minister of the Gospel in charge of an organized church, that person is qualified to be listed as an eligible voter in municipal elections if he or she will have lived in the city, town, or village for six months by the date of the next election. south carolina A person is qualified to be listed as an eligible voter in elections in the State of South Carolina, except municipal elections, if he has all the following qualifications at the time he applies for listing and if he takes the required oath or affirmation. (1) He is 21 years of age. (2) He is a citizen of the United States and of the State of South Carolina. (3) He will have lived in the State of South Carolina for one year, in his county for six months, and in his precinct for three months by the date of the next election. However, if the person is a minister in charge of an organized church or a teacher in the public schools, or the spouse of such a minister or teacher, that person is qualified if he or she will have lived in the State of South Carolina for six months by the date of the next election. (4) He has not been convicted of burglary, arson, obtaining goods or money under false pretenses, perjury, forgery, robbery, bribery, adultery, bigamy, wife-beating, housebreaking, receiving stolen goods, breach of trust with fraudulent intent, fornication, sodomy, incest, assault with intent to ravish, larceny, challenging or accepting a challenge to duel with a deadly weapon, or crimes against the election laws, or if so convicted his right to vote has been restored by pardon. (5) He has not been declared legally insane, idiotic, or incompetent by a court, or if so declared he has subsequently been declared legally sane or competent by a court. (6) He is not a pauper supported at public expense. (7) He is not otherwise registered or listed as eligible to vote in the county in which he applies for listing. A person who has all the above qualifications is also qualified to be listed as an eligible voter in municipal elections if he will have lived in his city or town for four months by the date of the next election. texas A person is qualified to be listed as an eligible voter in elections in the State of Texas if he has all the following qualifications at the time he applies for listing and if he takes the required oath or affirmation. (1) He will be 18 years of age within 60 days after applying for registration. (2) He is a citizen of the United States. (3) He is a resident of the State of Texas. (4) He has not been convicted of a felony, or if so convicted, he has been subsequently restored to full citizenship and suffrage or pardoned. (5) He has not been declared an idiot or a lunatic by a court, or if so declared, he has been subsequently declared legally sane or competent by a court. (6) He is not otherwise registered or listed as eligible to vote in the county in which he applies for listing. Editorial Note: For These are the addresses of each Examiner (State Supervisor), U.S. Office of Personnel Management. alabama Examiner (State Supervisor), U.S. Office of Personnel Management, Southeast Region, 75 Spring Street, SW., Atlanta, Georgia, 30303. georgia Examiner (State Supervisor), U.S. Office of Personnel Management, Southeast Region, 75 Spring Street, SW., Atlanta, Georgia, 30303. louisiana Examiner (State Supervisor), U.S. Office of Personnel Management, Southwest Region, 610 South Street, Room 804, New Orleans, Louisiana, 70130. mississippi Examiner (State Supervisor), U.S. Office of Personnel Management, Southeast Region, 802 State Street, Room 403, Jackson, Mississippi, 39201. Address effective December 1, 1979: 75 Spring Street, SW., Atlanta, Georgia, 30303. south Carolina Examiner (State Supervisor), U.S. Office of Personnel Management, Southeast Region, 75 Spring Street, SW., Atlanta, Georgia, 30303. texas Examiner (State Supervisor), U.S. Office of Personnel Management, Southwest Region, 1100 Commerce Street, Room 4C24, Dallas, Texas, 75242. (Reorganization Plan No. 2 of 1978 (43 FR 36037)) Editorial Note: For This appendix sets out the bases for loss of eligibility to vote and removal from an eligibility list. alabama A person loses his eligibility to vote in elections in the State of Alabama if: (1) He is no longer a legal resident of the State of Alabama or the county for which he is listed (a person may not vote in a county or precinct in which he is not a resident, but when a person removes from one precinct or ward to another precinct or ward within the same county, town, or city within three months before an election, he may vote in the precinct or ward from which he so removed); (2) He dies; (3) He is convicted of treason, murder, arson, embezzlement, malfeasance in office, larceny, receiving stolen property, obtaining property or money under false pretenses, perjury, subornation of perjury, robbery, assault with intent to rob, burglary, forgery, bribery, assault and battery on wife, bigamy, living in adultery, sodomy, incest, rape, crime against nature, or any crime punishable by imprisonment in the penitentiary, or of any infamous crime or crime involving moral turpitude, or vagrancy or being a tramp, or selling or offering to sell his vote or the vote of another, or of buying or offering to buy the vote of another, or of making or offering to make false return in any election by the people or in any primary election to procure the nomination or election of any person to any office, or of suborning any witness or registrar to secure the registration of any person as an elector, and has not been subsequently pardoned with restoration of his right to vote specifically expressed in the pardon; (4) He is declared legally insane by a court and has not been subsequently declared legally sane or competent by a court; or (5) He loses his citizenship in the United States or the State of Alabama. A person loses his eligibility to vote in municipal elections only, if he is no longer a legal resident of his city or town. Loss of eligibility to vote in a municipal election because of change of such residence does not result in loss of eligibility in any other election. georgia A person loses his eligibility to vote in elections in the State of Georgia if: (1) He is no longer a legal resident of the State of Georgia or the county for which he is listed; (2) He dies; (3) He is convicted of treason against the State, embezzlement of public funds, malfeasance in office, bribery or larceny, or of any crime involving moral turpitude, punishable by the laws of Georgia with imprisonment in the penitentiary, and has not been subsequently pardoned; (4) He is declared legally insane or idiotic by a court and has not been subsequently declared legally sane or competent by a court; or (5) He loses his citizenship in the United States or the State of Georgia. A person loses his eligibility to vote in municipal elections only, if he is no longer a legal resident of his city or town. Loss of eligibility to vote in a municipal election because of change of such residence does not result in loss of eligibility in any other election. louisiana A person loses his eligibility to vote in elections in the State of Louisiana if: (1) He is no longer a legal resident of the State of Louisiana or the parish for which he is listed, however, the removal from one parish to another does not deprive a person of the right to remain listed in the parish from which he has removed for the purpose of voting for district officers to be elected in a district which includes the parish to which he has removed, or for State officers, whether the parish is in the same district or not, until he has acquired the right to register or be listed and vote for such officers in the parish to which he has removed (the removal of a person from one precinct to another in the same parish does not deprive him of his right to remain listed in the parish from which he has removed until three months after the removal); (2) He dies; (3)(a) He is convicted of any crime punishable by imprisonment in the penitentiary and has not been subsequently pardoned with the express restoration of the franchise, or (b) he is convicted of a felony and has not subsequently received a pardon and full restoration of franchise. (4) He is declared legally incompetent or insane by a court and has not been subsequently restored to legal competency or sanity by a court; (5) He is dishonorably discharged from the Louisiana National Guard or the military service of the United States and has not been reinstated; (6) He deserts from the military service of the United States or the militia of the State of Louisiana, when called forth by the Governor or, in time of invasion, insurrection, or rebellion, by the President of the United States and has not returned to the command from which he deserted, made good the time lost in desertion, and served out the term of his original enlistment; (7) He becomes an inmate of any charitable institution, except the Soldiers Home and the United States Marine Hospital at Carville; or (8) He loses his citizenship in the United States or the State of Louisiana. A person loses his eligibility to vote in municipal elections only, if he is no longer a legal resident of his city or town. Loss of eligibility to vote in a municipal election because of change of such residence does not result in loss of eligibility in any other election. mississippi A person loses his eligibility to vote in elections in the State of Mississippi if: (1) He is no longer a legal resident of the State of Mississippi or the election district for which he is listed; (2) He dies; (3) He is convicted of arson, bigamy, bribery, burglary, embezzlement, forgery, obtaining money for goods under false pretenses, perjury, or theft and has not had his right to vote restored by the legislature; (4) He is declared legally insane by a court and has not been subsequently declared legally sane or competent by a court; or (5) He loses his citizenship in the United States. A person loses his eligibility to vote in municipal elections only, if he (1) is no longer a legal resident of his city or town, or (2) if he has, within two years before the next municipal election, been convicted within the municipality of violating the liquor laws of the State or the municipality, or (3) is at the time of the municipal election in default for taxes due the municipality for the two preceding years. Loss of eligibility to vote in a municipal election because of change of such residence or such conviction or such default in taxes does not result in loss of eligibility in any other election. south carolina A person loses his eligibility to vote in elections in the State of South Carolina if: (1) He is no longer a legal resident of the State of South Carolina or the county for which he is listed; (2) He dies; (3) He is convicted of burglary, arson, obtaining goods or money under false pretenses, perjury, forgery, robbery, bribery, adultery, bigamy, wife-beating, housebreaking, receiving stolen goods, breach of trust with fraudulent intent, fornication, sodomy, incest, assault with intent to ravish, larceny, challenging or accepting a challenge to duel with a deadly weapon, or crimes against the election laws and his right to vote has not been restored by pardon; (4) He is declared legally insane, idiotic or incompetent by a court and has not subsequently been declared legally sane or competent by a court; (5) He becomes a pauper supported at public expense; or (6) He loses his citizenship in the United States or the State of South Carolina. A person loses his eligibility to vote in municipal elections only if he is no longer a legal resident of his city or town. Loss of eligibility to vote in a municipal election because of change of residence does not result in a loss of eligibility in any other election. (7) He fails to register in accordance with State law requiring general registration of all previously registered voters every 10th year. However, he does not lose his eligibility to vote if he has attempted to register in accordance with State law and his application was rejected without legal cause or solely because his prior registration was by listing by an Examiner. texas A person loses his eligibility to vote in elections in the State of Texas if: (1) He is no longer a citizen of the United States; (2) He is no longer a resident of the State of Texas; (3) He dies; (4) He is convicted of a felony; (5) He is adjudged by a court of being mentally incompetent; or (6) He has a change of name through marriage or judgment of a court, and fails to present his registration certificate to the registrar with a signed request that his name be changed on the registration records. A person loses his eligibility to vote in elections of the county, municipality, or other political subdivision only, if he is no longer a resident of the subdivision on the day of the election. Loss of eligibility to vote in an election of a county, municipality, or other subdivision does not result in loss of eligibility in any other elections. Texas Forma Aprobada OMB No. 50R0592 Solicitud Para Ejercer El Derecho Del Voto La información que se le pide a continuació es con el objeto de determinar si usted es elegible para votar. Si se encuentra que usted es elegible, su nombre será certificado para que los oficiales apropiados del Estado lo agreguen a las listas oficiales para la votación. La autorización para solicitar la siguiente información está basada en el Acta del Derecho de Votar, enmendada. No se le exige que responda a las preguntas que se le harán a continuación, pero su cooperación es necesaria si usted desea que se le clasifique elegible para voter. Instrucciones para el solicitante: Haga el favor de llenar los espacios en blanco con la información que se le pide. Si necesita ayuda para contestar alguna pregunta, el examinador le ayudara. 1. Nombre __________ (Primer nombre) (Segundo nombre) (Apellido) 2. Sexo Masculino: o Femenino: o 3. Direccion permanente: _____ (Calle y no. de su apartamento, calle rural o localida (no caja postal) Ciudad _____ Zip code ____ 5. Direccion postal si es diferente de la mencionada arriba: Calle o Apartado Postal _____ Ciudad ___ Estado ___ Zip code ___ 6. Lugar de nacimiento: Ciudad ____ o Condado ____ Estado ____ o Pais ____ Cual fué su última dirección: _____ (Ciudad) _____ (Estado) _____ (Zip code) Es voluntario declarar su número de Seguro Social y su número de teléfono. Si Ud. prefiere declarar sólo uno de esos números o ninguno de los dos, está bien, eso NO será motivo para que su solicitud se considere incompleta. Esos números solo servirán para mantener la exactitud y la integridad de los archivos de éste registro. Si usted, sabiéndolo, da información falsa en esta solicitud, está cometiendo un crimen Federal que puede ser castigado con una multa o con encarcenlamiento. PARE AQUI. LLEVE ESTA FORMA AL EXAMINADOR. Solemnemente juro (o afirmo) que yo, el solicitante, soy de 18 años de edad o mayor, o que cumpliré 18 años dentro de 60 diás después de la fecha en que he presentado esta solicitud, y que soy ciudadano de los Estados Unidos, mantengo residencia legal en este Condado, he llenado todos los requisitos legales y entiendo que el hecho de dar información falsa con el objeto de que se me registre para la votación es un crimen. *El agente debe estar registrado para votar y debe ser: (Encierre en un círculo la palabra correspondiente) Esposo—Madre—Padre—Hijo—Hija Informacion Adicional La ley del Estado de Texas dice que una persona que ha sido convicta por haber cometido un crimen y que no ha sido perdonada, o una persona que ha sido declarada lunática o idiota y por lo tanto no se le considera competente, no está calificada para votar. Por esta razón las siguientes preguntas deben ser contestadas. A. Ha sido Ud. alguna vez convicto por haber cometido un crimen: Si o No o Si su respuesta a la pregunta anterior es afirmativa, ha sido usted perdonado y se le ha devuelto su derecho de votar? Si o No o B. Ha sido usted declarado por una corte idiota o lunático? Si o No o Si su respuesta es si, fué usted despues declarado por una corte sano o competente? Si o No o Apendice B Este apéndice enumera las calificaciones que re requiren para sercolocado en una lista de personas elegibles para votar. texas Una persona es considerada calificada para ser puesta en la lista de elegibles para votar en el Estado de Texas si llena los siguientes requisitos al momento de hacer su solicitud y si presta juramento (o afirmación) que se requiere. (1) Deberá cumplir 18 años de edad dentro de 60 dias despues de haber hecho la solicitud. (2) Debe ser ciudadano de los Estados Unidos. (3) Debe ser residente del Estado de Texas. (4) No ha sido convicto por un crimen, o si fué convicto alguna vez, se le han desde entonces restaurado sus derechos de ciudadanía y sufragio o ha sido perdonado. (5) No ha sido declarado por la corte come idiota o lunático, y si lo fué, ha side despues declarado legalmente sano o competente por una corte. (6) No está registrado para votar en ningún otro lugar de este Condado. Apendice D Este apéndice enumera las razones por las cuales puede usted perder el derecho a votar o por las cuales se le puede quitar de la lista de elegibles para votar. texas Una persona pierde su derecho a votar en las elecciones en el Estado de Texas si: (1) Ha dejado de ser ciudadano de los Estados Unidos; (2) Ha dejado de ser un residente del Estado de Texas; (3) Ha fallecido; (4) Ha sido convicto por haber cometido un crimen; (5) Ha sido declarado en la corte de ser mentalmente incompetente; (6) Ha cambiado de nombre por razones de matrimonio o por otros procedimientos legales en una corte y ha fallado de presentar el certificado correspondiente al encargado, dicho certificado debe ser acompañado de una petición firmada pidiendo que su nombre sea cambiado en los archivos de registro para votar. Una persona pierde su derecho a votar en las elecciones del condado, la municipalidad o cualquier otra sub-division politica solamente, si esa persona ha dejado de ser residente de ese lugar el dia de la eleccion. La pérdida de su elegibilidad para votar en una eleccíon de un condado, municipalidad o cualquier otra subdivisión politica no resulta en la pérdida del derecho a votar en otras elecciones. Autoridad: Los requisitos enumerados en esta Parte 801 emitidos bajo las secciones 7, 9, 79, Stat. 440; 42 U.S.C. 1973e, 1973g. Editorial Note: For
Title 45: Public Welfare
PART 801—VOTING RIGHTS PROGRAM
Section Contents
§ 801.101 Definitions.
§ 801.102 Timely filing required.
§ 801.103 Computation of time.
§ 801.104 Words denoting number and gender.
§ 801.201 Scope.
§ 801.202 Times and places for filing and forms of application.
§ 801.203 Procedures for filing application.
§ 801.204 Qualifications requirements.
§ 801.205 Action on the application.
§ 801.206 Review of notice of ineligibility for listing.
§ 801.207 Certification and publication of eligibility lists.
§ 801.301 Scope.
§ 801.302 Basis of challenge.
§ 801.303 Time and place of challenge.
§ 801.304 Form of challenge.
§ 801.305 Rejection and docketing of challenge.
§ 801.306 Summary denial of challenge by hearing officer.
§ 801.307 Notice of hearing.
§ 801.308 Rights and duties of parties.
§ 801.309 Continuance.
§ 801.310 Hearing.
§ 801.311 Powers of hearing officer.
§ 801.312 Witnesses.
§ 801.313 Subpena.
§ 801.314 Evidence.
§ 801.315 Decision.
§ 801.316 Action after challenge is sustained.
§ 801.317 Appeal.
§ 801.401 Scope.
§ 801.402 Bases for removals.
§ 801.403 Procedure for removals determined by examiners.
§ 801.404 Notification of removals.
§ 801.501 Scope.
§ 801.502 Making a complaint.
§ 801.503 Processing a complaint.
Appendix A to Part 801
Appendix B to Part 801
Appendix C to Part 801
Appendix D to Part 801
Subpart A—General Provisions
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§ 801.101 Definitions.
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§ 801.102 Timely filing required.
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§ 801.103 Computation of time.
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§ 801.104 Words denoting number and gender.
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Subpart B—Listing on Eligibility List
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§ 801.201 Scope.
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§ 801.202 Times and places for filing and forms of application.
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§ 801.203 Procedures for filing application.
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§ 801.204 Qualifications requirements.
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§ 801.205 Action on the application.
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§ 801.206 Review of notice of ineligibility for listing.
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§ 801.207 Certification and publication of eligibility lists.
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Subpart C—Challenges to Listing on Eligibility List
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§ 801.301 Scope.
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§ 801.302 Basis of challenge.
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§ 801.303 Time and place of challenge.
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§ 801.304 Form of challenge.
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§ 801.305 Rejection and docketing of challenge.
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§ 801.306 Summary denial of challenge by hearing officer.
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§ 801.307 Notice of hearing.
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§ 801.308 Rights and duties of parties.
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§ 801.309 Continuance.
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§ 801.310 Hearing.
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§ 801.311 Powers of hearing officer.
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§ 801.312 Witnesses.
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§ 801.313 Subpena.
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§ 801.314 Evidence.
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§ 801.315 Decision.
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§ 801.316 Action after challenge is sustained.
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§ 801.317 Appeal.
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Subpart D—Removals From Eligibility List
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§ 801.401 Scope.
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§ 801.402 Bases for removals.
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§ 801.403 Procedure for removals determined by examiners.
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§ 801.404 Notification of removals.
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Subpart E—Voting Complaint
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§ 801.501 Scope.
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§ 801.502 Making a complaint.
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§ 801.503 Processing a complaint.
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Appendix A to Part 801
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Sworn to (or affirmed) and subscribed before me on this date ____________________
Examiner ____________________
Sworn to (or affirmed) and subscribed before me this date ____________________
Examiner ____________________
Sworn to (or affirmed) and subscribed before me this date ____________________
Examiner ____________________
Notice of Ineligibility Issued—No. ____________________
Sworn to (or affirmed) and subscribed before me this date ____________________
Examiner ____________________
Notice of Ineligibility Issued—No. ____________________
Notice of Ineligibility Issued—No. ____________________
Sworn to (or affirmed) and subscribed before me this date ____________________
Examiner ____________________Appendix B to Part 801
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Appendix C to Part 801
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Appendix D to Part 801
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Número de su teléfono____________________
Dónde y cuando fué usted convicto ____________________
Fué esta convicción por un crimen que lo descalifica para votar? Si o No o____________________
