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

   1. (a) the envelope shall include the following:"AFFIRMATIONAre you a citizen of the United States of America? Yes NoWill you be 18 years old on or before election day? Yes NoIf you checked "no" in response to either of the two above questions, do not complete this form. You must be a United States citizen to vote. If you fail to provide proof of United States citizenship, you will only be permitted to vote for federal offices. Information on how to provide proof of citizenship is included on or with this form.Name of Voter _________________________________________________________First MiddleLastDriver 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______________________________________________________________________CityCountyStateZip CodeTribal Identification Number or Alien Registration Number (optional) ______________________________Telephone Number (optional) ______________________________________________Email Address (optional)__________________________________________________";
   2. (b) beginning on January 1, 2027, immediately following the portion of the envelope described in Subsection (1)(a), the envelope shall include the following:"Do you consent to the election officer providing the following information to the political party with which you affiliate? (optional): The email address you provided above? Yes No The phone number you provided above? Yes No";
   3. (c) following the statement required under Subsections (1)(a) and (b), the envelope shall include the following:"Last four digits of Social Security Number ____________________________Last former address at which I was registered to vote (if known)______________________________________________________________________CityCountyStateZip CodeVoting Precinct (if known) _________________________________________________I, (please print your full name)__________________________do solemnly swear or affirm:That I 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; andSubject 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 calendar days immediately before this election.Signed ______________________________________________________________________Dated ______________________________________________________________________In accordance with Section 20A-3a-506, wilfully providing false information above is a class B misdemeanor under Utah law and is punishable by imprisonment and by fine.PRIVACY INFORMATIONVoter registration records contain some information that is available to the public, such as your name, address, and age range. Your date of birth, driver license number, state identification card number, and social security number are available only to an authorized government entity. Your email address and phone number are also only available to an authorized government entity, unless you have consented, above, to disclose them to the political party with which you choose to affiliate.REQUEST FOR ADDITIONAL PRIVACY PROTECTIONIn addition to the protections provided above, you may request that your voter registration record be withheld from public disclosure if you are, or reside with: an individual who is a victim of, or is threatened with, domestic violence or dating violence; a law enforcement officer; a member of the armed forces; a public figure; or an individual who is protected by a court order.To make this request for additional privacy protection, you must prove that you qualify by submitting an at-risk designation request form, and any required proof, to your county clerk. You may obtain the form, and information on the proof required, from your county clerk or at the following website [insert the website address specified by the lieutenant governor].CITIZENSHIP AFFIDAVITName: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 ApplicantIn 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."; and
   4. (d) the following statement shall appear after the statement described in Subsection (1)(c):"BALLOT NOTIFICATIONSDo you consent to receive communications about the status of your ballot and other official communications, by text, at the phone number you provided above? Yes No Indicate below how you want to vote in upcoming elections:_____ Mail a ballot to me._____ Do not mail a ballot to me. I will vote in person."

2. (2) The provisional ballot envelope shall include:

   1. (a) a unique number;
   2. (b) a detachable part that includes the unique number;
   3. (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;
   4. (d) an insert containing written instructions on how a voter may sign up to receive ballot status notifications via the ballot tracking system described in Section 20A-3a-401.5; and
   5. (e) on or with the form on the envelope, the statement described in Subsection 20A-2-104(1)(c).

Amended by Chapter 408, 2026 General Session