1. A. Each mandatory voter registration agency shall provide a declaration form with each voter registration application that is distributed with each application for service or assistance, and with each recertification, renewal, or change of address form relating to such service or assistance.

2. B. The declaration form shall include the following, in order:

   1. 1. the question:

      “If you are not registered to vote where you live now, would you like to apply to register to vote here today?”;

   2. 2. boxes for the applicant to check to indicate whether the applicant would like to register to vote or declines to register to vote (failure to check either box being deemed to constitute a declination to register to vote for purposes of providing assistance in completion of the registration application form), together with the statement (in close proximity to the boxes and in prominent type):

      “IF YOU DO NOT CHECK EITHER BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER TO VOTE AT THIS TIME.”

   3. 3. if the mandatory voter registration agency provides public assistance, the statement:

      “Applying to register or declining to register to vote will not affect the amount of assistance that you will be provided by this agency.”

   4. 4. the statement:

      “If you would like help in filling out the voter registration application form, we will help you. The decision whether to seek or accept help is yours. You may fill out the application form in private.”

   5. 5. the statement:

      1. a. the first blank shall be filled in with the department’s name and the second blank shall be filled in with the department’s telephone number or other contact information;

      “For assistance in completing the voter registration application form outside our office, contact ___________ at ____________.”

   6. 6. the statement:

      1. a. the first blank shall be filled in with the department’s local office physical location and the second blank shall be filled in with the department’s mailing address used to accept applications for service or assistance, recertifications, renewals, and changes of address forms; and

      “If completed outside our office, this declaration form and your completed voter registration application form (if you filled one out) should be returned to __________ or ____________.”

   7. 7. the statement:

      “If you believe that someone has interfered with your right to register or to decline to register to vote, your right to privacy in deciding whether to register or in applying to register to vote, or your right to choose your own political party or other political preference, you may file a complaint with the Louisiana Secretary of State, Commissioner of Elections, P.O. Box 94125, Baton Rouge, LA 70804-9125, Telephone (toll-free) 1-800-883-2805.”

3. C. Completed declaration forms shall be retained by the mandatory voter registration agency for at least 24 months.
4. D. No information relating to a declination to register to vote in connection with an application made at a mandatory voter registration agency may be used for any purpose other than voter registration.

Authority Note

AUTHORITY NOTE: Promulgated in accordance with R.S. 18:116, R.S. 36:742, 42 U.S.C. §1973gg et seq., and the Permanent Injunction issued in “Scott, et al. v. Schedler, et al.” (Docket No. 11-926), United States District Court, Eastern District of Louisiana.

Historical Note

HISTORICAL NOTE: Promulgated by the Department of State, Elections Division, LR 39:2799 (October 2013).