Republic of Palau Office of Election Commission P.O. Box 826 Koror, Republic of Palau 96940 Ph. No.

: (680)488-1554/4543 Fax No.: (680)488-3327 Email:[email protected]

Revised April 2007

Affidavit No.:

AFFIDAVIT FOR APPLICATION

TO REGISTER TO VOTE

) REPUBLIC OF PALAU
) SS STATE OF
)
HAMLET OF

Direction: This affidavit is divided into three sections. All applicants must complete Section 1. Only applicants registering
for the first time must complete Section 2, and only applicants transferring or re-registering must complete Section 3. Review and
complete all required questions on both sides of this affidavit. If a question is not applicable, mark N/A. Your signature on this
affidavit attests to the fact that you have answered all questions truthfully under oath.

Penalties: All citizens should be aware that, pursuant to Republic of Palau law, whoever knowingly gives false information as to
his/her name, address or period of residence in the voting state for the purpose of establishing his/her eligibility to register to vote, or
conspires with another person for the purpose of encouraging his/her false registration to vote or illegal voting, or pays or offers to
pay or accepts payment either for registration to vote or for voting in any election or referendum shall upon conviction thereof, be
fined not less than $ 2,000 nor more than $ 10,000 or shall be imprisoned not more than five years, or both. 23 PNC §110(a).

SECTION 1: ALL APPLICANTS

(1) My full name is
(Last) (First) (Middle) Sex

(2) I am also known as

(3) I was born at on the day of in the year

(4) My age is . My Social Security Number is .

(5) My current address is and my telephone number is .

(6) My occupation is at State. If you are a student, print the

name of the institution you are attending .

(7) Are you a citizen of the Republic? Yes No

(8) Were you naturalized as a citizen of the Republic? Yes No . If yes, provide the day, month, and
years on which you were naturalized . Provide proof of naturalization.

(9) Are you currently in jail serving a sentence for a felony? Yes No .

(10) Have you been judged mentally incompetent by a court? Yes No .

SECTION 2: APPLICANTS REGISTERING TO VOTE FOR THE FIRST TIME

In order to establish residency in a particular State or hamlet, you must have been physically present in that State or hamlet on a
reasonably continuous basis within a 30 day period (or the state's minimum residency period if greater than 30 days) with the intent to
establish your permanent home in such State or hamlet. You need not currently live in such State or hamlet in order to be a resident
there if your intent to establish your permanent home in that State or hamlet has not changed. First time registrant must provide
documents to proof of Palau citizenship.
("Reasonably continuous basis" means at least 25 days out of a period of 30 consecutive days with an
interruption of no more than 48 cosecutive hours within the 30 day period)
Your answers to the following questions will allow the Election Commission to ascertain the State, and Hamlet if applicable,
in which you are resident for voting purposes.
(1) I currently physically reside at State in Hamlet.

(2) I wish to register to vote as a resident of State in Hamlet.

(3) Have you ever lived in the hamlet and state in which you seek to register to vote for at least a period of 30 days?
Yes No If yes, how many days/months/years did you live in that Hamlet and State and provide
approximate date

(4) If you live in the State and hamlet in which you seek to register to vote, is this the place that you consider your
permanent home? Yes No
Republic of Palau Office of Election Commission P.O. Box 826 Koror, Republic of Palau 96940 Ph. No.: (680)488-1554/4543 Fax No.: (680)488-3327 Email:[email protected]
If you have not physically resided, whithin the last 30 days, at the State and Hamlet in which you seek to register to
vote, provide answers to the following questions. If you have so resided there, skip down to applicant's signature.
(5) Do you still consider that the State and hamlet in which you seek to register as your permanent home?
Yes No If no, provide the State and Hamlet that you do consider your permanent home.
State in Hamlet.

(6) I am typically physically present in the State or Hamlet in which I seek to register to vote for
days/months out of a year.

(7) Do you maintain a home in the State or Hamlet in which you seek to register to vote? Yes No
Do you maintain a home in any other State or hamlet? Yes No If yes, in what State and Hamlet?
State in Hamlet.

(8) Do you or your family own property in the State or Hamlet in which you seek to register to vote? Yes No
Do you or your family own property in any other State or Hamlet? Yes No If yes, in what State and
Hamlet? State in Hamlet.

(9) Do you have any family members who physically reside in the State or Hamlet in which you seek to register to vote?
Yes No If yes, what family members reside there?

(10) (a) Do you conduct any business in the State or hamlet in which you seek to register to vote? Yes No

(b) Are you involved in any of the social, political, cultural, government, traditional, or religious affairs of the State or
or Hamlet or any organizations or institutions operating within the State or Hamlet in which you seek to register to
vote? Yes No

(c) Do you have any other connections to the State or Hamlet in which you seek to register to vote?
Yes No

(11) If you answered yes to any of the questions in (10), please provide details here:

SECTION 3: APPLICANTS TRANSFERRING OR RE-REGISTERING TO VOTE

(1) I was last registered to vote as a resident of State in Hamlet.

(2) I wish to register to vote as a resident of State in Hamlet.

(3) I currently physically reside at State in Hamlet. I have physically

resided at this location on a reasonably continuous basis for days/months/years immediately
proceeding this date on which I now offer to register.

(4) Have you lived in the State and Hamlet in which you wish to register to vote for at least 25 days within the past 30 day
period, with an interruption of no more than 48 consecutive hours within the 30 day period? Yes No

(5) Do you intend to establish your permanent home in the State and Hamlet in which you seek to register to vote?
Yes No . If no, provide the State and Hamlet that you do consider your permanent home:
State in Hamlet
I solemnly swear/affirm that the foregoing statement are true.

Signature of Applicant Date Notary Public/Election Officer Date

FOR OFFICE USE ONLY

This is to certify that the Affidavit numbered has been accepted by the Election Commission in
support of the application to register to vote of the applicant:
(Last) (First) (Middle)
The applicant is registered to vote in National Elections.
The applicant is also registered to vote in State Elections as a resident of State in Hamlet.

Print Name & Title of Official Administer Oath Signature of Official Date