Title 20A Chapter 6 Section 105

Election Code
Ballot Form
Section 105
Provisional ballot envelopes.


20A-6-105.   Provisional ballot envelopes.

            (1) Each election officer shall ensure that provisional ballot envelopes are printed in substantially the following form:


Are you a citizen of the United States of America? Yes No

Will you be 18 years old on or before election day? Yes No

If you checked "no" in response to either of the two above questions, do not complete this form.

            Name of Voter _________________________________________________________

                                                First                            Middle                                    Last

            Driver License or Identification Card Number _________________________________

            State of Issuance of Driver License or Identification Card Number _________________

            Date of Birth ___________________________________________________________

            Street Address of Principal Place of Residence


                        City                             County                                    State                Zip Code

            Telephone Number (optional) ______________________________________________

            Last four digits of Social Security Number ____________________________

            Last former address at which I was registered to vote (if known)


                        City                             County                                    State                Zip Code

            Voting Precinct (if known) _________________________________________________

            I, (please print your full name)__________________________do solemnly swear or affirm:

            That I am currently registered to vote in the state of Utah and am eligible to vote in this election; that I have not voted in this election in any other precinct; that I am eligible to vote in this precinct; and that I request that I be permitted to vote in this precinct; and

            Subject to penalty of law for false statements, that the information contained in this form is true, and that I am a citizen of the United States and a resident of Utah, residing at the above address; and that I am at least 18 years old and have resided in Utah for the 30 days immediately before this election.

Signed ______________________________________________________________________

Dated ______________________________________________________________________

            In accordance with Section 20A-3-506, wilfully providing false information above is a class B misdemeanor under Utah law and is punishable by imprisonment and by fine."

            "The portion of a voter registration form that lists a person's driver license or identification card number, social security number, and email address is a private record. The portion of a voter registration form that lists a person's date of birth is a private record, the use of which is restricted to government officials, government employees, political parties, or certain other persons.

            If you believe that disclosure of any information contained in this voter registration form to a person other than a government official or government employee is likely to put you or a member of your household's life or safety at risk, or to put you or a member of your household at risk of being stalked or harassed, you may apply to the lieutenant governor or your county clerk to have your entire voter registration record classified as private."



            Name at birth, if different:

            Place of birth:

            Date of birth:

            Date and place of naturalization (if applicable):

            I hereby swear and affirm, under penalties for voting fraud set forth below, that I am a citizen and that to the best of my knowledge and belief the information above is true and correct.


                                                                                                            Signature of Applicant

            In accordance with Section 20A-2-401, the penalty for willfully causing, procuring, or allowing yourself to be registered to vote if you know you are not entitled to register to vote is up to one year in jail and a fine of up to $2,500."

            (2) The provisional ballot envelope shall include:

            (a) a unique number;

            (b) a detachable part that includes the unique number; and

            (c) a telephone number, internet address, or other indicator of a means, in accordance with Section 20A-6-105.5, where the voter can find out if the provisional ballot was counted.

Amended by Chapter 373, 2014 General Session