Florida Voter Registration Application Part 1 Instructions (DS-DE 39, R1S-2.040, F.A.C.)(eff.

. 10/2013) To Register in Florida, you must be: a U.S. citizen, a Florida resident, at least 18 years old (you may pre-register at 16 or 17, but cannot vote until you are 18). If you have been convicted of a felony, or if a court has found you to be mentally incapacitated as to your right to vote, you cannot register until your right to vote is restored. If you do not meet any ONE of these requirements, you are not eligible to register.

Informacin en espaol: Sirvase llamar a la oficina del supervisor de elecciones de su condado si le interesa obtener este formulario en espaol.

Where to Register: You can register to vote by completing this application and delivering it in person or by mail to any supervisor of elections office, office that issues drivers licenses, or voter registration agency (public assistance office, center for independent living, office serving persons with disabilities, public library, or armed forces recruitment office) or the Division of Elections. Mailing addresses are on page 2 of this form. Deadline to Register: The deadline to register to vote is 29 days before any election. You can update your registration record at any time, but for a Primary Election, party changes must be completed 29 days before that election. You will be contacted if your new application is incomplete, denied or a duplicate of an existing registration. Your Voter Information Card will be mailed to you once you are registered. Identification (ID) Requirements: New applicants must provide a current and valid Florida drivers license number (FL DL#) or Florida identification card number (FL ID#). If you do not have a FL DL# or FL ID#, then you must provide the last four digits of your Social Security number (SSN). If you do not have any of these numbers, check None. If you leave the field and box blank, your new registration may be denied. See section 97.053(6), Fla.Stat. Special ID requirements: If you are registering by mail, have never voted in Florida, and have never been issued one of the ID numbers above, include one of the following with your application, or at a later time before you vote: 1) A copy of an ID that shows your name and photo (acceptable IDs--U.S. Passport, debit or credit card, military ID, student ID, retirement center ID, neighborhood association ID, or public assistance ID); or 2) A copy of an ID that shows your name and current residence address (acceptable documents--utility bill, bank statement, government check, paycheck, or other government document). The special ID is not required if you are 65 or older, have a temporary or permanent physical disability, are a member of the active uniformed services or merchant marine who is absent from the county for active duty, or a spouse or dependent thereof, or are currently living outside the U.S. but otherwise eligible to vote in Florida. Political Party Affiliation: Florida is a closed primary election state. In primary elections, registered voters can only vote for their registered partys candidates in a partisan race on the ballot. In a primary election, all registered voters, regardless of party affiliation, can vote on any issue, nonpartisan race, and race where a candidate faces no opposition in the General Election. If you do not indicate your party affiliation, you will be registered with no party affiliation. For a list of political parties, visit the Division of Elections website at: http://election.dos.state.fl.us/ Race/Ethnicity: It is optional to list your race or ethnicity. Boxes: Please check boxes () where applicable.

Questions?
Contact the Supervisor of Elections in your county: http://election.dos.state.fl.us/SOE/supervisor_elections.shtml Visit the Florida Division of Elections website at: http://election.dos.state.fl.us. CRIMINAL OFFENSE: It is a 3rd degree felony to submit false information. Maximum penalties are $5,000 and/or 5 years in prison. PUBLIC RECORD: Once filed, all information including your phone number and email address as provided become public record except for the following which can only be used for voter registration purposes: your FL DL#, FL ID#, SSN, where you registered to vote, and whether you declined to register or to update your voter registration record at a voter registration agency. Your signature can be viewed but not copied. (Section 97.0585, Fla. Stat.)

Numbered rows 1 through 7 and 12 must be completed for a new registration.

Florida Voter Registration Application
Part 2 Form (DS-DE #39, R1S-2.040, F.A.C.)(eff. 10/2013)

The downloadable/printable online form is available at: http://election.dos.state.fl.us/pdf/webappform.pdf

This is:

1 2 3 4 5 6 7 8 9 10 11

New Registration Record Update/Change (e.g., Address, Party Affiliation, Name, Signature) Request to Replace Voter Information Card OFFICIAL USE ONLY Are you a citizen of the United States of America? YES NO
I affirm that I am not a convicted felon, or if I am, my right to vote has been restored. I affirm that I have not been adjudicated mentally incapacitated with respect to voting or, if I have, my right to vote has been restored. (MM-DD-YYYY)

Date of Birth

City City City

Florida Driver License (FL DL) or Florida identification (FL ID) Card Number

Last Name

FVRS No: If no FL DL or FL ID, then provide

Last 4 digits of Social Security Number

I have
NONE of these numbers.

First Name Apt/Lot/Unit Apt/Lot/Unit Apt/Lot/Unit Gender

Middle Name County

Name Suffix

(Jr., Sr., I, II, etc.):

Address Where You Live (legal residence-no P.O. Box) Mailing Address (if different from above address) Address Where You Were Last Registered to Vote Former Name (if name is changed)

Zip Code Zip Code Zip Code

State or Country State

M F

State or Country of Birth

Telephone No. (optional) ( )

Email me SAMPLE BALLOTS if option is available in my county. (See Public Record Notice above) My email address is: Race/Ethnicity (Check only one) (Check only one if applicable)

Party Affiliation (Check only one. If left blank, you will be registered without party affiliation) Florida Democratic Party Republican Party of Florida No party affiliation Minor party (print party name):

______________________

American Indian/Alaskan Native Asian/Pacific Islander Black, not of Hispanic Origin Hispanic White, not of Hispanic Origin Multi-racial Other:________________
SIGN/ MARK HERE

I am an active duty Uniformed Services or Merchant

Marine member

I am a spouse or a dependent of an active duty uniformed

services or merchant marine member

I will need assistance with voting. I am interested in becoming a poll worker.

Date

I am a U.S. citizen residing outside the U.S.

12

Oath: I do solemnly swear (or affirm) that I will protect and defend the Constitution of the United States and the Constitution of the State of Florida, that I am qualified to register as an elector under the Constitution and laws of the State of Florida, and that all information provided in this application is true.

Address your envelope to your County Supervisor of Elections. (Updated 10/1/2013)

ALACHUA COUNTY Supervisor of Elections 111 SE 1st Avenue Gainesville, FL 32601-6819 352-374-5252 BAKER COUNTY Supervisor of Elections PO Box 505 MacClenny FL 32063-0505 904-259-6339 BAY COUNTY Supervisor of Elections 830 W. 11th St. Panama City FL 32401 850-784-6100 BRADFORD COUNTY Supervisor of Elections PO Box 58 Starke FL 32091-2110 904-966-6266 BREVARD COUNTY Supervisor of Elections PO Box 410819 Melbourne FL 32941-0819 321-264-6740 BROWARD COUNTY Supervisor of Elections PO Box 029001 Fort Lauderdale FL 33302 954-357-7050 CALHOUN COUNTY Supervisor of Elections 20859 Central Ave. E., Rm 117 Blountstown FL 32424-2264 850-674-8568 CHARLOTTE COUNTY Supervisor of Elections 226 Taylor Street, Unit 120 Punta Gorda FL 33950 941-833-5400 CITRUS COUNTY Supervisor of Elections 120 N. Apopka Ave. Inverness FL 34450-4238 352-341-6740 CLAY COUNTY Supervisor of Elections PO Box 337 Green Cove Springs FL 32043-0337 904-284-6350 COLLIER COUNTY Supervisor of Elections Rev Dr MLK Jr Bldg 3295 Tamiami Trail E Naples FL 34112-5758 239-252-VOTE (8683) COLUMBIA COUNTY Supervisor of Elections 971 W. Duval St., Suite 102 Lake City FL 32055-3734 386-758-1026 DESOTO COUNTY Supervisor of Elections PO Box 89 Arcadia FL 34265-4451 863-993-4871 DIXIE COUNTY Supervisor of Elections PO Box 2057 Cross City FL 32628-2057 352-498-1216 DUVAL COUNTY Supervisor of Elections 105 E. Monroe St. Jacksonville FL 32202-3215 904-630-1414 ESCAMBIA COUNTY Supervisor of Elections PO Box 12601 Pensacola FL 32591-2601 850-595-3900

FLAGLER COUNTY Supervisor of Elections PO Box 901 Bunnell FL 32110-0901 386-313-4170 FRANKLIN COUNTY Supervisor of Elections 47 Ave. F Apalachicola FL 32320-2311 850-653-9520 GADSDEN COUNTY Supervisor of Elections PO Box 186 Quincy FL 32353 850-627-9910 GILCHRIST COUNTY Supervisor of Elections 112 S. Main St., Room 128 Trenton FL 32693-3249 352-463-3194 GLADES COUNTY Supervisor of Elections PO Box 668 Moore Haven FL 33471-0668 863-946-6005 GULF COUNTY Supervisor of Elections 401 Long Ave. Port St. Joe FL 32456-1707 850-229-6117 HAMILTON COUNTY Supervisor of Elections 1153 US Hwy. 41 NW, Suite 1 Jasper FL 32052-5856 386-792-1426 HARDEE COUNTY Supervisor of Elections 311 N. 6th Ave. Wauchula FL 33873-2361 863-773-6061 HENDRY COUNTY Supervisor of Elections PO Box 174 LaBelle FL 33975-0174 863-675-5230 HERNANDO COUNTY Supervisor of Elections 20 N. Main St., Room 165 Brooksville FL 34601-2864 352-754-4125 HIGHLANDS COUNTY Supervisor of Elections PO Box 3448 Sebring FL 33871-3448 863-402-6655 HILLSBOROUGH COUNTY Supervisor of Elections 601 E. Kennedy Blvd., 16th Floor Tampa FL 33602-4932 813-272-5850 HOLMES COUNTY Supervisor of Elections 201 N. Oklahoma St., Suite 102 Bonifay FL 32425-2243 850-547-1107 INDIAN RIVER COUNTY Supervisor of Elections 4375 43rd Ave. Vero Beach FL 32967-1024 772-226-3440 JACKSON COUNTY Supervisor of Elections PO Box 6046 Marianna FL 32447-6046 850-482-9652 JEFFERSON COUNTY Supervisor of Elections 380 W. Dogwood St. Monticello FL 32344-1470 850-997-3348 LAFAYETTE COUNTY Supervisor of Elections PO Box 76 Mayo FL 32066-0076 386-294-1261

LAKE COUNTY Supervisor of Elections PO Box 457 Tavares FL 32778-0457 352-343-9734 LEE COUNTY Supervisor of Elections PO Box 2545 Fort Myers FL 33902-2545 239-533-VOTE (8683) LEON COUNTY Supervisor of Elections PO Box 7357 Tallahassee FL 32314-7357 850-606-VOTE (8683) LEVY COUNTY Supervisor of Elections 421 S. Court St. Bronson FL 32621-6520 352-486-5163 LIBERTY COUNTY Supervisor of Elections PO Box 597 Bristol FL 32321-0597 850-643-5226 MADISON COUNTY Supervisor of Elections 239 SW Pinckney St. Madison FL 32340 850-973-6507 MANATEE COUNTY Supervisor of Elections PO Box 1000 Bradenton FL 34206-1000 941-741-3823 MARION COUNTY Supervisor of Elections PO Box 289 Ocala FL 34478-0289 352-620-3290 MARTIN COUNTY Supervisor of Elections PO Box 1257 Stuart FL 34995-1257 772-288-5637 MIAMI-DADE COUNTY Supervisor of Elections PO Box 521550 Miami FL 33152-1550 305-499-VOTE (8683) MONROE COUNTY Supervisor of Elections 530 Whitehead St., Suite 101 Key West FL 33040-6577 305-292-3416 NASSAU COUNTY Supervisor of Elections 96135 Nassau Place, Suite 3 Yulee FL 32097-8635 904-491-7500 OKALOOSA COUNTY Supervisor of Elections 302 Wilson St. N., Suite 102 Crestview FL 32536-3440 850-689-5600 OKEECHOBEE COUNTY Supervisor of Elections 304 NW 2nd St., Room 144 Okeechobee FL 34972-4120 863-763-4014 ORANGE COUNTY Supervisor of Elections PO Box 562001 Orlando FL 32856-2001 407-836-2070 OSCEOLA COUNTY Supervisor of Elections 2509 E. Irlo Bronson Memorial Hwy. Kissimmee FL 34744-4909 407-742-6000 PALM BEACH COUNTY Supervisor of Elections PO Box 22309 West Palm Beach FL 33416-2309 561-656-6200

PASCO COUNTY Supervisor of Elections PO Box 300 Dade City FL 33526-0300 352-521-4302 PINELLAS COUNTY Supervisor of Elections 13001 Starkey Road Largo FL 33773-1416 727-464-VOTE (8683) POLK COUNTY Supervisor of Elections PO Box 1460 Bartow FL 33831-1460 863-534-5888 PUTNAM COUNTY Supervisor of Elections 2509 Crill Ave., Suite 900 Palatka FL 32177-4267 386-329-0224 SANTA ROSA COUNTY Supervisor of Elections 6495 Caroline St., Suite F Milton FL 32570-4592 850-983-1900 SARASOTA COUNTY Supervisor of Elections PO Box 4194 Sarasota FL 34230-4194 941-861-8600 SEMINOLE COUNTY Supervisor of Elections PO Box 1479 Sanford FL 32772-1479 407-585-VOTE (8683) ST. JOHNS COUNTY Supervisor of Elections 4455 Ave. A, Suite 101 St. Augustine FL 32095-5200 904-823-2238 ST. LUCIE COUNTY Supervisor of Elections 4132 Okeechobee Road Fort Pierce FL 34947 772-462-1500 SUMTER COUNTY Supervisor of Elections 900 N. Main St. Bushnell FL 33513-5008 352-569-1540 SUWANNEE COUNTY Supervisor of Elections 220 Pine Ave. SW Live Oak FL 32064-2315 386-362-2616 TAYLOR COUNTY Supervisor of Elections PO Box 1060 Perry FL 32348-1060 850-838-3515 UNION COUNTY Supervisor of Elections 175 W. Main St. Lake Butler FL 32054 386-496-2236 VOLUSIA COUNTY Supervisor of Elections 125 W. New York Ave. DeLand FL 32720-5415 386-736-5930 WAKULLA COUNTY Supervisor of Elections PO Box 305 Crawfordville FL 32326-0305 850-926-7575 WALTON COUNTY Supervisor of Elections 571 E. Nelson Ave. (US Hwy. 90) DeFuniak Springs FL 32433-1378 850-892-8112 WASHINGTON COUNTY Supervisor of Elections 1331 South Blvd., Suite 900 Chipley FL 32428-2233 850-638-6230