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INDIANA VOTER REGISTRATION APPLICATION (VRG-7)

State Form 50504 (R8/5-12)
Indiana Election Commission
You can use this application to: Box 13: Voter Identification Number In Box 13, you are required to provide your Indiana
Apply to register to vote in Indiana or drivers license number as issued by the Indiana Bureau of Motor Vehicles. If you do not
Change your name and address on your voter registration record. have an Indiana drivers license, provide the last four digits of your social security number.
To register you must: If you do not have an Indiana drivers license number, or a social security number, a voter
identification number will be assigned to you.
Be a citizen of the United States;
Box 14: If this is an application for a name change, provide your previous name in Box 14.
Be at least 18 years old on the day of the next general or municipal election;
If you have not changed your name, skip this question.
Have lived in your precinct for at least 30 days before the next election (except for
Box 15: Skip this question if the address where you live has a street name and number
certain military voters); and
(such as 100 Maple Street). If you have a rural route or star route address, please draw a
Not currently be imprisoned after being convicted of a crime. simple map that shows the nearest crossroads or street intersection and where your
If you move: residence is located. If you do not live in a house or other building, please draw a map that
You must transfer your registration whenever you move out of your precinct. shows where you usually sleep and the nearby streets.
You may use this application to transfer your registration. You may mail or hand deliver Box 16: This application cannot be processed without the voters original signature
the completed application to your county registration office. in this section. DO NOT FAX OR EMAIL THIS FORM AFTER COMPLETING IT.
To complete this form: Registration Deadlines: In order to be processed for the next election, this application
FILL IN ALL THE BOXES THAT APPLY TO YOU IN BLUE OR BLACK INK must be postmarked or hand delivered to your county voter registration office no later than
Box 4: Residence Address Type or print the address where you live (number, street, 29 days before the next election. If your county registration office receives this application
apartment number, city/town, and ZIP code). If your address is a rural route or star route, after that day, you will be unable to vote in the next election. If you miss this deadline, your
be sure to include the box number. If this address does not have a street number, draw a registration application will be processed when registration reopens. Some military voters
map in Box 15. and their family members can register until noon on election day. Contact your county voter
Box 5: Mailing Address If this address is the same as Box 4, just print SAME in this box. registration office for information if you may qualify to do so.
Box 6: Previous Voter Registration Address If you have been registered previously, Acknowledgment Notice: You will be sent a notice from your county voter registration
please list your most recent registration address. office that acknowledges receipt of your voter registration application. The notice informs
you whether your registration application was approved by the county voter registration
Boxes 8 and 9: These questions are optional. Your application will be processed even if
office. The notice may identify where you can vote. If your registration application is
you do not answer these questions.
incomplete, you may be contacted and asked to provide additional information. If you have
Box 10: Identification Documentation If you are registering to vote in Indiana for the first not received an acknowledgment notice within 30 days of filing this application you should
time, and you are sending this application by mail, you must provide identification contact your county voter registration office.
documentation. Identification may include a current and valid photo id, current utility bill,
Questions? Call your county voter registration office or the Indiana Election Division for
bank statement, government check, paycheck, or government document that shows the
assistance.
name and address of the voter. You may include a copy of your identification with this
application. Do not mail an ORIGINAL copy of your document! If you do not provide
identification with this application or to the county voter registration office before election Indiana Election Division
day, you will be asked for it the first time you vote. 302 West Washington Street, Room E204
Box 11:If you check no in response to the question in Box 11, you may not complete this Indianapolis, Indiana 46204-2743
application. Telephone: 317-232-3939 or Toll-free Indiana only: 800-622-4941
Box 12: The question in Box 12 requires a person to be at least 18 years of age by the www.in.gov/sos/elections
next general or municipal election. If you check no in response to the question in Box 12,
you may not complete this application.
If Not Typed, Please Print in Blue or Black Ink
New registration Indiana county where you live: Date processed Township/Precinct County Tracking Number
Check boxes COUNTY
1 that apply:
Address change (See Box 6) 2
Name change (See Box 14) USE ONLY
Gender Last Name First Name Middle Name or Initial Suffix
3 Female Jr. Sr. II III IV
Male
Residence Address (No Post Office Boxes) Apt. No. City / Town State Zip Code
4 IN
Mailing Address, if different from Box 4, if same, print SAME Apt. No. City / Town State Zip Code
5
Previous Voter Registration Address County Apt. No. City / Town State Zip Code
6
Date of Birth (mm/dd/yy) Telephone number (If available) E-mail (If available) Are you including identification documentation?
7 8 9 10 (See instructions for Box 10 above.)
Yes No
Voter Identification Number
Are you a citizen of the United States Will you be at least 18 years of age on
Provide your 10-digit Indiana issued drivers Drivers License Number
of America? or before election day?
11 12 13 license number. If you do not possess an
Indiana drivers license, then provide the last
Social Security Number
Yes No Yes No 4 digits of your social security number here. None
If you have changed your name, what was your name Last Name First Name Middle Name or Initial Suffix
14 before you changed it? If you have not changed Jr. Sr. II III IV
your name, skip this question.
Map/Diagram: If your residence has no address, street number or name (such I authorize my voter registration at any other address to be cancelled. I swear or affirm that:
as 100 Maple Street), please draw a map showing where your residence is I am a citizen of the United States.
located, include roads and landmarks. Otherwise, skip this question. I will be at least 18 years of age at the next general or municipal election.
N I will have lived in my precinct for at least 30 days before the next election.
I am not currently in prison after being convicted of a crime.
All the above information and all other statements on this form are true.
I understand that if I sign this statement knowing that it is not true I am committing perjury and
can be fined up to $10,000, jailed for up to three years or both.
15
16 Signature of Applicant Date
W E

If applicant is unable to fill out the application due to disability, the person who helped the applicant with this
application lists their name, address and telephone number in the box below. (Telephone number is optional.)
Name Address City/Town Telephone Number (optional)
S
50504
 Indiana County Voter Registration Offices
Sign and Mail this Completed Voter Registration Application to the county where you live or to the Indiana Election Division
ADAMS DUBOIS JAY NOBLE STARKE
Adams Co. Circuit Court Clerk Dubois Co. Circuit Court Clerk Jay Co. Circuit Court Clerk Noble Co. Circuit Court Clerk Starke Co. Circuit Court Clerk
112 S. Second One Courthouse Square, Room 104 120 North Court 101 North Orange Street Courthouse, Room E
P.O. Box 189 Jasper, IN 47546 -3058 Portland, IN 47371 2195 Albion, IN 46701 1092 53 East Washington Street
Decatur, IN 46733 0189 (812) 481-7035 (260) 726-6917 (260) 636-2736 Knox, IN 46534 - 1197
(260) 724-5300 ext. 2110 (574) 772-9160
ELKHART JEFFERSON OHIO
ALLEN Elkhart Co. Circuit Court Clerk Jefferson Co. Circuit Court Clerk Ohio Co. Circuit Court Clerk STEUBEN
Allen Co. Board of Voter Registration County Office Bldg. Rm. L4 Courthouse, Room 203 P.O. Box 185 Steuben Co. Circuit Court Clerk
nd
1 West Superior Street, Suite 111 117 North 2 Street 300 East Main Street Rising Sun, IN 47040 - 0185 55 South Public Square
Fort Wayne, IN 46802 - 1213 Goshen, IN 46526 - 3243 Madison, IN 47250 - 3594 (812) 438-2610 Angola, IN 46703 1945
(260) 449-7154 (574) 535-6774 (812) 265-8926 (260) 668-1000 ext. 2220
ORANGE
BARTHOLOMEW FAYETTE JENNINGS Orange Co. Circuit Court Clerk SULLIVAN
Bartholomew Co. Circuit Court Clerk Fayette Co. Circuit Court Clerk Jennings Co. Circuit Court Clerk 1 Court Street Sullivan Co. Circuit Court Clerk
P.O. Box 924 401 Central Ave P.O. Box 385 Orange County Courthouse Courthouse, Room 370
Columbus, IN 47202 - 0924 Connersville, IN 47331 Vernon, IN 47282 - 0385 Paoli, IN 47454 - 9632 100 Courthouse Square
(812) 379-1604 (765) 825-1813 (812) 352-3080 (812) 723-2649 Sullivan, IN 47882 - 0370
(812) 268-4657
BENTON FLOYD JOHNSON OWEN
Benton Co. Circuit Court Clerk Floyd Co. Circuit Court Clerk Johnson Co. Voter Registration Owen Co. Circuit Court Clerk SWITZERLAND
th
706 E. 5 Street 311 Hauss Square, Rm. 233 P.O. Box 451 P.O. Box 146 Switzerland Co. Circuit Court Clerk
Suite 37 New Albany, IN 47150-3584 Franklin, IN 46131 - 0451 Spencer, IN 47460 - 0146 Courthouse
Fowler, IN 47944 - 1556 (812) 948-5419 (317) 346-4466 (812) 829-5028 212 West Main
(765) 884-0930 Vevay, IN 47043 - 1180
FOUNTAIN KNOX PARKE (812) 427-4415
BLACKFORD Fountain Co. Circuit Court Clerk Knox Co. Circuit Court Clerk Parke Co. Circuit Court Clerk
th
Blackford Co. Circuit Court Clerk P.O. Box 183 111 North 7 Street, Ste 27 116 West High Street TIPPECANOE
110 W. Washington St. Covington, IN 47932 Vincennes, IN 47591 - 2022 Room 204 Tippecanoe Co. Board of Elections and
Hartford City, IN 47348 - 2298 (765) 793-2192 (812) 895-4928 Rockville, IN 47872 - 1781 Registration
rd
(765) 348-7217 (765) 569-5132 20 N. 3 Street
FRANKLIN KOSCIUSKO Lafayette, IN 47901
BOONE Franklin Co. Circuit Court Clerk Kosciusko Co. Circuit Court Clerk PERRY (765) 423-9316
Boone Co. Circuit Court Clerk 459 Main Street 121 North Lake Street Perry Co. Circuit Court Clerk
212 Courthouse Square Brookville, IN 47012 - 1486 Warsaw, IN 46580 - 2788 2219 Payne Street TIPTON
Lebanon, IN 46052 - 2100 (765) 647-5111 (574) 372-2332 Tell City, IN 47586 - 2832 Tipton Co. Circuit Court Clerk
(765) 483-5251 (812) 547-3741 101 East Jefferson
FULTON LAGRANGE Tipton, IN 46072 - 1901
BROWN Fulton Co. Circuit Court Clerk LaGrange Co. Circuit Court Clerk PIKE (765) 675-2795
Brown Co. Circuit Court Clerk 815 Main Street 105 North Detroit Street Pike Co. Circuit Court Clerk
nd
P.O. Box 85 Rochester, IN 46975 - 0524 LaGrange, IN 46761 - 1801 801 Main St. 2 Floor UNION
Nashville, IN 47448 - 0085 (574) 223-7713 (260) 449-6392 Petersburg, IN 47567 - 1298 Union Co. Circuit Court Clerk
(812) 988-5511 (812) 354-6025 26 West Union Street
GIBSON LAKE Liberty, IN 47353 - 1396
CARROLL Gibson Co. Circuit Court Clerk Lake Co. Board of Elections and PORTER (765) 458-6121
Carroll Co. Circuit Court Clerk P.O. Box 630 Registration Porter Co. Board of Voter Registration
101 W. Main St. Princeton, IN 47670 - 0630 2293 North Main Street, Suite 16 Administration Center VANDERBURGH
Delphi, IN 46923 (812) 385-2541 Crown Point, IN 46307 Suite 105 Vanderburgh Co. Voter Registration
(765) 564-6795 (219) 755-3795 155 Indiana Avenue Civic Center Complex, Room 106
GRANT Valparaiso, IN 46383 - 5555 1 NW Martin Luther King Jr. Boulevard
CASS Grant Co. Voter Registration LAPORTE (219) 465-3484 Evansville, IN 47708 - 1828
Cass Co. Circuit Court Clerk Courthouse, Suite B-9 LaPorte Co. Board of Voter Registration (812) 435-5222
th
200 Court Park, Room 103 101 E. 4 Street 813 Lincolnway, Suite 103 POSEY
Logansport, IN 46947 - 3192 Marion, IN 46952 - 4055 LaPorte, IN 46350 - 3401 Posey Co. Circuit Court Clerk VERMILLION
(574) 753-7870 (765) 664-9880 (219) 326-6808 ext. 2250 P.O. Box 606 Vermillion Co. Circuit Court Clerk
Mt. Vernon, IN 47620 - 0606 P.O. Box 10
CLARK GREENE LAWRENCE (812) 838-1339 Newport, IN 47966 - 0008
Clark Co. Circuit Court Clerk Greene Co. Circuit Court Clerk Lawrence Co. Circuit Court Clerk (765) 492-5350
th
501 E. Court Avenue P.O. Box 229 916 15 St. Room 31 PULASKI
Jeffersonville, IN 47130-4090 Bloomfield, IN 47424 - 0229 Bedford, IN 47421 - 3800 Pulaski Co. Circuit Court Clerk VIGO
(812) 285-6329 (812) 384-2015 (812) 277-2036 112 East Main Vigo Co. Board of Voter Registration
Room 230 Courthouse, Room 3
rd
CLAY HAMILTON MADISON Winamac, IN 46966 - 1394 33 South 3 Street
Clay Co. Circuit Court Clerk Hamilton Co. Board of Voter Registration Madison Co. Board of Voter Registration (574) 946-3313 Terre Haute, IN 47808 - 3472
th
609 E. National Ave. Room 211 1 Hamilton County Square 16 East 9 Street, Suite 208 (812) 462-3393
Brazil, IN 47834 - 0033 Suite 13 Anderson, IN 46016 - 1588 PUTNAM
(812) 448-9023 Noblesville, IN 46060 - 2230 (765) 641-9657 Putnam Co. Circuit Court Clerk WABASH
(317) 776-9632 P.O. Box 546 Wabash Co. Circuit Court Clerk
CLINTON MARION Greencastle, IN 46135 - 0546 69 West Hill Street
Clinton Co. Circuit Court Clerk HANCOCK Marion Co. Board of Voter Registration (765) 655-1538 Wabash, IN 46992 - 3151
265 Courthouse Square Hancock Co. Voter Registration 200 East Washington, W131 (260) 563-0661 ext. 238
Frankfort, IN 46041 - 1993 9 East Main Street Indianapolis, IN 46204 - 3355 RANDOLPH
(765) 659-6337 Room 227 (317) 327-5040 Randolph Co. Circuit Court Clerk WARREN
Greenfield, IN 46140 - 2320 P.O. Box 230 Warren Co. Circuit Court Clerk
CRAWFORD (317) 462-1171 MARSHALL Winchester, IN 47394 - 0230 125 North Monroe Street
Crawford Co. Circuit Court Clerk Marshall Co. Circuit Court Clerk (765) 584-4717 Suite 11
P.O. Box 375 HARRISON 211 West Madison Street Williamsport, IN 47993 - 1198
Court St. Harrison Co. Circuit Court Clerk Plymouth, IN 46563 - 1762 RIPLEY (765) 762-2834
English, IN 47118 - 0375 Courthouse, Room 203 (574) 935-8713 Ripley Co. Circuit Court Clerk
(812) 338-2565 300 North Capitol Avenue P.O. Box 177 WARRICK
Corydon, IN 47112 - 1155 MARTIN 115 N. Main Street Warrick Co. Circuit Court Clerk
DAVIESS (812) 738-8790 Martin Co. Circuit Court Clerk Versailles, IN 47042 1 County Square
Daviess Co. Circuit Court Clerk 129 Main St. (812) 689-4783 Suite 220
200 E. Walnut Street HENDRICKS P.O. Box 120 Boonville, IN 47601 - 1594
P.O. Box 739 Hendricks Co. Circuit Court Clerk Shoals, IN 47581 RUSH (812) 897-6161
Washington, IN 47501 - 0739 355 S Washington, Suite 218 (812) 247-3651 Rush Co. Circuit Court Clerk
nd
(812) 254-8679 Danville, IN 46122 - 1795 101 East 2 Street. Rm 209 WASHINGTON
(317) 745-9313 MIAMI Rushville, IN 46173 - 0429 Washington Co. Circuit Court Clerk
DEARBORN Miami Co. Circuit Court Clerk (765) 932-2086 99 Public Square North
Dearborn Co. Circuit Court Clerk HENRY P.O. Box 184 Salem, IN 47167 - 2098
215 W. High Street Henry Co. Voter Registration Peru, IN 46970 - 0184 ST. JOSEPH (812) 883-5748
Lawrenceburg, IN 47025 - 1909 P.O. Box B (765) 472-2671 St. Joseph Co. Board of Voter Registration
th
(812) 537-8869 New Castle, IN 47362 - 1044 City-County Building, 4 Floor WAYNE
(765) 529-9310 MONROE 227 West Jefferson Boulevard Wayne Co. Circuit Court Clerk
DECATUR Monroe Co. Voter Registration South Bend, IN 46601 - 1871 301 E. Main Street
th
Decatur Co. Circuit Court Clerk HOWARD 214 W 7 Street, Ste 140 (574) 235-9521 Richmond, IN 47374
150 Courthouse Square Howard Co. Board of Voter Registration Bloomington, IN 47401 (765) 973-9304
Suite 244 104 North Buckeye Street, Room 104B (812) 349-2690 SCOTT
Greensburg, IN 47240 - 2080 Kokomo, IN 46901 - 4667 Scott Co. Circuit Court Clerk WELLS
(812) 663-8223 (765) 456-2219 MONTGOMERY 1 East McClain Avenue Wells Co. Circuit Court Clerk
Montgomery Co. Circuit Court Clerk Scottsburg, IN 47170 - 1885 102 West Market Street
DEKALB HUNTINGTON 100 East Main Street, Room 203 (812) 752-8421 Suite 201
Dekalb Co. Circuit Court Clerk Huntington Co. Circuit Court Clerk P.O. Box 768 Bluffton, IN 46714 - 2091
P.O. Box 230 P.O. Box 228 Crawfordsville, IN 47933 - 0768 SHELBY (260) 824-6480
100 S. Main Street 201 North Jefferson Street (765) 364-6437 Shelby Co. Circuit Court Clerk
Auburn, IN 46706 - 0230 Huntington, IN 46750 P.O. Box 198 WHITE
(260) 925-9787 (260) 358-4820 MORGAN Shelbyville, IN 46176 - 0198 White Co. Circuit Court Clerk
Morgan Co. Circuit Court Clerk (317) 392-6324 P.O. Box 350
DELAWARE JACKSON 180 S. Main Street, Ste 1 Monticello, IN 47960 - 0350
Delaware Co. Board of Voter Registration Jackson Co. Circuit Court Clerk Martinsville, IN 46151 - 1556 SPENCER (574) 583-1531
100 West Main Street, Room 200 111 South Main Street (765) 342-1029 Spencer Co. Circuit Court Clerk
Muncie, IN 47305 - 2836 P.O. Box 318 P.O. Box 12 WHITLEY
(765) 747- 7812 Brownstown, IN 47220 -0122 NEWTON 200 Main Street Whitley Co. Circuit Court Clerk
(812) 358-6120 Newton Co. Circuit Court Clerk Rockport, IN 47635 - 0012 101 West Van Buren Street
P.O. Box 49 (812) 649-6017 Columbia City, IN 46725 - 2087
JASPER Kentland, IN 47951 - 0049 (260) 248-3164
Jasper Co. Circuit Court Clerk (219) 474-6081
115 West Washington
Rensselaer, IN 47978
(219) 866-4929