Instructions for Registering to Vote Using this Application

1. Completetheapplicationonlyifyoucheck‘yes’toquestions1and2.

2. UsethisapplicationtoregistertovoteinNebraskaortoupdateyourname,address,orpartyonyourNebraskavoterregistrationrecord.

3. Clearlyprintalltherequestedinformationinthedesignatedspaces.

4. Readtheoath,verifytheinformationbysigninganddatingtheapplication.

5. Returnthecompletedformtoyourcountyelectionoffice.

Bypersonalmessenger/agent-mustbedeliveredtoyourcountyelectionofficebythe3rdFridaypriortotheelection.

Inperson-mustappearatyourcountyelectionofficeby6p.m.onthe 2ndFridaypriortotheelection.

6. TheCountyElectionofficewillsendeither:

Anacknowledgmenttoyouverifyingtheinformationonyourapplicationandadvisingyouofyourpollinglocation,or

Anincompletenoticetoyourequestingadditionalinformationtoensureyourvoterregistrationrecordisaccurate,or

Arequestforvalidphotoid,orotherdocumentationifyouareafirst timeregistrantinNebraska,registeringbymail.

7. Ifyouhavequestions,youmaycontactyourlocalelectionoffice,oryou maycontacttheNebraskaSecretaryofStatebyphoneat402-471-2555 ortollfreeat888-727-0007;viaourwebsite:www.sos.ne.gov;oremail SOS.ELECT@nebraska.gov.

8. MailingaddressesfortheNebraskaCountyElectionOfficesmaybefoundonthebackofthisapplication.

Nebraska Secretary of State’sOfficialVoterRegistrationApplication

http://ne.gov/go/NEreg2vote

Nebraska’sOnlineVoterRegistrationSystem

www.sos.ne.gov

Applicant’s Signature: Date:

Please print your previous registration information (Providing this information avoids errors and duplicate registrations)

____________________________/ ___________________________________________________

Print your full and complete Legal Name to avoid errors and duplicate registrations

LastName FirstName MiddleNameorInitial MaidenorFormerLastName

Postal(Mailing)Address,ifdifferent:

NebraskaDriver’sLicenseNumberorStateI.D. Last4digitsSSN,ifnoNeb.DL#

DateofBirth(MM/DD/YYYY)

______/______/____________ PlaceofBirth:

Name Address

StreetAddress Unit/Apt.# City State Zip

Current Residential Address: (Please print)

Important - Party Affiliation - Please Mark OneDemocratic Republican Libertarian Nonpartisan

Other ______________________________________________________________ If checking other, print the name of the party

Note:If youwish to vote in both partisan and nonpartisan primary elections for the state and local offices,youmust indicateapoliticalpartyaffiliationon theregistrationapplication. Ifyouregisterwithoutapoliticalparty affiliation (nonpartisan), youwill receive only the nonpartisan ballots for the state and local offices at primary elections. If you registerwithout a political party affiliation (nonpartisan), youmay vote in partisan primaryelectionsforcongressionaloffices.Optional-Toassistinverifyinginformation,pleaseprovide: Check the box if any are private.

PhoneNumber() WorkorCellNumber()

Email

Applicant’sOath:Tothebestofmyknowledgeandbelief,Ideclareunderpenaltyofelectionfalsification,that:(1)IliveintheStateofNebraskaattheaddressprovidedinthisapplication;(2)Ihavenotbeenconvictedofafelonyor,ifconvicted,ithasbeenatleasttwoyearssinceIcompletedmysentenceforthefelony,includinganyparoleterm;(3)Ihavenotbeenofficiallyfoundtobenoncomposmentis(mentallyincompetent);and(4)IamacitizenoftheUnitedStates.WARNING: Any registrant who signs this application knowing that any of the information in the application is false shall be guilty of a Class IV felony under section 32-1502 of the statutes of Nebraska. The penalty for a Class IV Felony is up to two years imprisonment and twelve months post-release supervision, a fine of up to $10,000.00, or both.

Source: V O T EForm10302019

DateApplicationReceivedinElectionOffice:____________________________RegistrationTakenby:____________________

(Fullnameormarkifunabletosign)

Nameandaddressofpersonprovidingassistance:

Suffix

NEBRASKA VOTER REGISTRATION APPLICATION1. AreyouacitizenoftheUnitedStatesofAmerica? Yes No

2. Areyouatleast18yearsofage,orwillyoube18yearsofageonorbeforeYes No

If you checked NO in response to either of the questions, do not complete this application.

Bymail-mustbepostmarkedbythe3rdFridaypriortotheelection.IfyouaremailingthisapplicationandareafirsttimeregistrantinNebraska, statuterequiresacopyofaphotoidentificationwhichiscurrentandvalidoracopyofautilitybill,bankstatement,governmentcheck,paycheck,orothergovernmentdocumentthatiscurrentandshowsyournameandresidenceaddress.

thefirstTuesdayfollowingthefirstMondayinNovemberofthisyear?

Find your county listed in red below. Print the nam

e & address in the space provided above. D

etach, stamp and m

ail.

Print Your Return Address________________________________________________________________________________________________________________________

To: ______________________________________ County Election O

fficial

(County)______________________________________(Address)

______________________________________ , Nebraska

(City or Town)

_________________ (Zip)

Adams / POB 2067

Hastings / 68902-2067Antelope / PO Box 26 Neligh / 68756-0026Arthur / POB 126 Arthur / 69121Banner / POB 67 Harrisburg / 69345Blaine / 145 Lincoln Ave Brewster / 68821Boone / 222 S 4th St Albion / 68620-1247Box Butte / POB 678 Alliance / 69301Boyd / POB 26 Butte / 68722Brown / 148 W

4th St Ainsworth / 69210Buffalo / POB 1270 Kearney / 68848Burt / POB 87 Tekam

ah / 68061Butler / 451 N 5th St David City / 68632Cass / 201 M

ain St Plattsm

outh / 68048Cedar / POB 47 Hartington / 68739Chase / POB 1299 Im

perial / 69033Cherry / POB 120 Valentine / 69201

Cheyenne / POB 217 Sidney / 69162Clay / 111 W

Fairfield St Clay Center / 68933Colfax / 411 E 11th St Schuyler / 68661Cum

ing / 200 S Lincoln St. Rm

100 / West Point / 68788

Custer / 431 S 10th St Broken Bow / 68822Dakota / POB 39 Dakota City / 68731Dawes / 451 M

ain St Chadron / 69337Dawson / 700 N W

ashington Rm

A / Lexington / 68850Deuel / POB 327 Chappell / 69129Dixon / POB 546 Ponca / 68770Dodge / 435 N Park Rm

102 Frem

ont / 68025Douglas / 12220 W

Center Rd Om

aha / 68144Dundy / Box 506 Benkelm

an / 69021-0506Fillm

ore / POB 307 Geneva / 68361Franklin / POB 146 Franklin / 68939Frontier / POB 40 Stockville / 69042

Furnas / POB 387 Beaver City / 68926Gage / POB 429 Beatrice / 68310Garden / POB 350 Oshkosh / 69154Garfield / POB 218 Burwell / 68823-0218Gosper / POB 136 Elwood / 68937Grant / Box 139 Hyannis / 69350Greeley / Box 287 Greeley / 68842Hall/121SPineStSte8Grand Island / 68801Ham

ilton / 1111-13th St Ste 1 Aurora / 68818-2017Harlan / Box 698 Alm

a / 68920-0698Hayes / POB 370 Hayes Center / 69032Hitchcock / POB 248 Trenton / 69044Holt / POB 329 O’Neill / 68763Hooker / Box 184 M

ullen / 69152Howard / POB 25 St Paul / 68873Jefferson / 411-4th St Fairbury / 68352

Johnson / Box 416 Tecum

seh / 68450Kearney / POB 339 M

inden / 68959Keith / 511 N Spruce Ste 102 Ogallala / 69153Keya Paha / POB 349 Springview / 68778Kim

ball / 114 E 3rd St Ste 6 Kim

ball / 69145Knox / POB 166 Center / 68724Lancaster / 601 N 46th St Lincoln / 68503Lincoln / 301 N Jeffers Rm

101 North Platte / 69101Logan / POB 8 Stapleton / 69163Loup / POB 187 Taylor / 68879M

adison / POB 290 M

adison / 68748M

cPherson / PO Box 122 Tryon / 69167M

errick / POB 27 Central City / 68826M

orrill / POB 610 Bridgeport / 69336Nance / POB 338 Fullerton / 68638Nem

aha / 1824 N St Ste 201 Auburn / 68305

Nuckolls / POB 366 Nelson / 68961Otoe / 1021 Central Ave Rm

103 Nebraska City / 68410Pawnee / POB 431 Pawnee City / 68420Perkins / POB 156 Grant / 69140Phelps / Box 404 Holdrege / 68949Pierce / 111 W

Court Rm 1

Pierce / 68767Platte / 2610 14th St Colum

bus / 68602Polk / POB 276 Osceola / 68651Red W

illow / 502 Norris Ave M

cCook / 69001Richardson / 1700 Stone St Room

203 / Falls City / 68355Rock / POB 367 Bassett / 68714Saline / POB 865 W

ilber / 68465Sarpy / 501 Olson Dr Ste 4 Papillion / 68046Saunders / POB 61 W

ahoo / 68066Scotts Bluff / 1825 10th St Gering / 69341Seward / POB 190 Seward / 68434

Sheridan / POB 39 Rushville / 69360Sherm

an / POB 456 Loup City / 68853Sioux / POB 158 Harrison / 69346Stanton / POB 347 Stanton / 68779Thayer / 225 N 4th Rm

201 Hebron / 68370Thom

as / POB 226 Thedford / 69166Thurston / POB 159 Pender / 68047Valley / 125 S 15th St Ste 202 / Ord / 68862W

ashington / POB 466 Blair / 68008W

ayne / 510 Pearl St Ste 5 / W

ayne / 68787W

ebster / POB 250 Red Cloud / 68970W

heeler / POB 127 Bartlett / 68622York / 510 Lincoln Ave York / 68467

First ClassPostage Required