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INDIANA VOTER REGISTRATION APPLICATION (VRG-7)

State Form 50504 (R20 / 4-20) For election info, see: www.indianavoters.com
Indiana Election Division

You can use this application to: Apply to register to vote Box 4: Residence Address Print the address where you Acknowledgment Notice: You will be sent a notice from
in Indiana or change your name and address on your live. If your address is a rural route, include the box number. your county voter registration office acknowledging receipt
record or transfer your registration if you move out of your If your residence has no address or street number, write a of your application. The notice informs you whether your
precinct. short description of its location in Box 4 or attach a map. application was approved by the county voter registration
To register you must: Be a citizen of the United States; be Boxes 10 or 11: If you check “no” in response to either office. If your application is incomplete, you will be asked
at least 18 years old on the day of the next general or question in Boxes 10 or 11, do not complete this to provide additional information. If you do not receive a
municipal election; have lived in your precinct for at least application. notice within 30 days of filing this application, contact your
30 days before the next election; and not currently be Box 12: Voter Identification Number: You are required county voter registration office.
imprisoned after being convicted of a crime. to provide your Indiana driver’s license number as issued
If you are registering to vote in Indiana for the first time, and by the Indiana Bureau of Motor Vehicles. If you do not Indiana Election Division
send this application by mail, you must provide additional have an Indiana driver’s license, provide the last four 302 West Washington Street, Room E204
residence documentation before voting. If the county is digits of your social security number. If you do not have Indianapolis, IN 46204-2743
able to match your driver’s license number or social security an Indiana driver’s license number, or a social security Telephone: (317) 232-3939
number with an existing Indiana identification record number, you must indicate “None”. Toll-free (Indiana only): (800) 622-4941
bearing the same number, name and date of birth you www.in.gov/sos/elections
Box 14: This application cannot be processed without
provide on the application, you have met the requirement. the voter’s original signature in this section.
You can also meet this requirement by submitting proof of Registration Deadline: This application must be
residence with this application or anytime up until election APPLICANT’S RECEIPT FROM INDIVIDUAL ACCEPTING
postmarked or hand delivered to your county voter CUSTODY OF A COMPLETED VOTER REGISTRATION FORM
day. Proof of residence can be met by submitting either: registration office no later than 29 days before the next
(1) a COPY of your current and valid photo identification or (not a receipt from the county for voter registration purposes)
election. If you miss this deadline, your application will be
(2) a current utility bill, bank statement, government check, processed when registration reopens.
paycheck, or government document that shows your name NOTE: If you accept a completed form from another person, in order
Box 15: If you or the Indiana Election Division do not file to submit his or her registration for consideration, you must submit
and address at the address you provided on this
this application with the county voter registration office, the completed form to the county voter registration office or Indiana
application. Please do not send originals. Cover any
the person who accepts custody of the application (with Election Division by noon 10 days after receipt or the registration
account information with a permanent marker.
the exception of a member of the same household) must deadline, whichever occurs first.
FILL IN ALL APPLICABLE BOXES IN BLUE OR BLACK INK. complete this certification before filing the application with
DO NOT FAX OR EMAIL FORM AFTER COMPLETING IT. the county voter registration office or the Indiana Election I accepted custody of this completed application on ___/____/20___.
Mail or hand deliver the completed application to your Division by noon 10 days after receipt or the registration
county registration office (addresses on reverse side) or deadline, whichever occurs first.
the Indiana Election Division. _______________________________________________________
Printed Name

_______________________________________________________
Residence Address

Please detach and give the receipt above to the applicant if you are accepting custody of a completed application.
New registration Indiana county where you live: Date processed Township / precinct County tracking number
Check boxes COUNTY USE
1 that apply:
Address change (See Box 6) 2
Name change (See Box 13) 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) if no address, write short description or attach map. Apartment Number City / Town State ZIP Code
4 IN
Mailing Address, if different from Box 4, if same, print “SAME” Apartment Number City / Town State ZIP Code
5
Previous Voter Registration Address County Apartment Number City / Town State ZIP Code
6
Date of Birth (mm/dd/yy) Telephone number (Optional) E-mail (Optional)
7 8 9

Are you a citizen of the Will you be at least 18 years of age Establish a Voter Identification Number—Applicant must provide a number or indicate “None”.
United States of America? on or before election day? Provide your 10-digit Indiana issued driver’s Indiana Driver’s License Number or Bureau of Motor Vehicles ID Card Number
license number. If you do not possess an Last 4 Digits of Social Security Number
10 Yes No 11 Yes No 12 Indiana driver’s license, then provide the last 4 None
digits of your social security number here. If you
have none of these, check “None”.
If you changed your name, what was your Last Name First Name Middle Name or Initial Suffix
13 name before you changed it? If you have not Jr. Sr. II III IV
changed your name, skip this question.
I authorize my voter registration at any other address to be cancelled. I swear or affirm that: CERTIFIED STATEMENT OF ACCEPTANCE
 I am a citizen of the United States. To be completed by a person who accepts custody of the completed application
 I will be at least 18 years of age at the next general or municipal election. before filing with a county voter registration office or Indiana Election Division.
 I will have lived in my precinct for at least 30 days before the next election. Does not apply to a person accepting a form from member of household.
 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 affirm under the penalties for perjury that I accepted custody of this completed
I understand that if I sign this statement knowing that it is not true I am committing perjury and can be fined application from the applicant on (insert date): ____/_____/20___.
14 up to $10,000, jailed for up to three years or both. 15
Signature of Applicant Date (mm/dd/yy) ____________________________________________________________________
Printed Name

If applicant is unable to sign the application due to a disability, the person who wrote the applicant’s name on the line ____________________________________________________________________
above at the applicant’s request, must provide his/her name and address below. Residence Address
Name Address Telephone number (Optional)
____________________________________________________________________
Signature
If you accept a completed form from another person, you must submit it to the county voter registration office or Indiana Election Division by noon 10 days after receipt or the registration deadline, whichever occurs first. 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 County Circuit Court Clerk Dubois Co. Circuit Court Clerk Jay Co. Circuit Court Clerk Noble Co. Circuit Court Clerk Starke County Election
112 S 2nd St Rm A One Courthouse Square 120 North Court Street, Ste. 209 101 North Orange Street 53 East Washington Street, P.O. Box 395
Decatur, IN 46733-1618 Jasper, IN 47546-3058 Portland, IN 47371 Albion, IN 46701-1092 Knox, IN 46534-1197
(260) 724-5300 ext. 2104 (812) 481-7035 (260) 726-4951 (260) 636-2736 ext. 1806 (574) 772-9160

ALLEN ELKHART JEFFERSON OHIO STEUBEN

Allen Co. Voter Registration Elkhart Co. Voter Registration Office Jefferson County Voter Registration Ohio Co. Circuit Court Clerk Steuben Co. Circuit Court Clerk
Rousseau Centre 117 North 2nd Street, Lower Level Courthouse, Room 203 P.O. Box 185 55 South Public Square
1 East Main Street, Suite 176 Goshen, IN 46526 300 E. Main Street Rising Sun, IN 47040-0185 Angola, IN 46703-1945
Ft. Wayne, IN 46802 (574) 535-6775 Madison, IN 47250-3594 (812) 438-2610 (260) 668-1000 EXT 2220
(260) 449-7154 (812) 265-8926
FAYETTE ORANGE SULLIVAN
BARTHOLOMEW Fayette Co. Election Board JENNINGS Orange Co. Circuit Court Clerk Sullivan Co. Circuit Court Clerk
Bartholomew County Clerk 401 Central Avenue Jennings County Election Office Orange County Courthouse Courthouse, Room 370
P.O. Box 924 Connersville, IN 47331 24 Pike St., P.O. Box 385 1 Court Street 100 Courthouse Square
Columbus, IN 47202 (765) 825-1813 Vernon, IN 47282-0385 Paoli, IN 47454-9632 Sullivan, IN 47882-0370
(812) 379-1604 (812) 352-3080 (812) 723-2649 (812) 268-4657
FLOYD
BENTON Floyd Co. Circuit Court Clerk JOHNSON OWEN SWITZERLAND
Benton Co. Circuit Court Clerk 311 Hauss Square, Rm. 235 Johnson Co. Voter Registration Owen Co. Circuit Court Clerk Switzerland Co. Circuit Court Clerk
706 E. 5th Street, Suite 37 New Albany, IN 47150 P.O. Box 451 60 S. Main St. Courthouse
Fowler, IN 47944-1556 (812) 948-5419 Franklin, IN 46131-0451 Spencer, IN 47460- 0146 212 West Main Street
(765) 884-0930 (317) 346-4467 (812) 829-5028 Vevay, IN 47043-1180
FOUNTAIN (812) 427-4415
BLACKFORD Fountain Co. Circuit Court Clerk KNOX PARKE
Blackford Co. Circuit Court Clerk 301 4th Street, P.O. Box 183 Knox County Voter Registration Parke Co. Circuit Court Clerk TIPPECANOE
110 West Washington Street Covington, IN 47932 111 N. 7th Street, Suite 27 116 West High St., Room 204 Tippecanoe Co. Board of Elections &
Hartford City, IN 47348-2298 (765) 793-6230 Vincennes, IN 47591-2022 Rockville, IN 47872-1781 Registration
(765) 348-7217 (812) 895-4927 (765) 569-5132 20 N. 3rd Street
FRANKLIN P.O. Box 619
BOONE Franklin County Voter Registration KOSCIUSKO PERRY Lafayette, IN 47902
Boone County Voter Registration Office 459 Main Street Kosciusko Co. Circuit Court Clerk Perry Co. Circuit Court Clerk (765) 423-9316
212 Courthouse Square Brookville, IN 47012-1486 121 N. Lake Street, D162 2219 Payne Street
Lebanon, IN 46052-2126 (765) 647-5111 ext. 3 Warsaw, IN 46580-2788 Tell City, IN 47586-2832 TIPTON
(765) 482-3510 (574) 372-2332 (812) 547-3741 Tipton Co. Circuit Court Clerk
FULTON 101 East Jefferson Street
BROWN Fulton Co. Circuit Court Clerk LAGRANGE PIKE Tipton, IN 46072-1901
Brown County Election Board 815 Main Street LaGrange County Voter Registration Pike Co. Circuit Court Clerk (765) 675-2795
20 East Main Street Rochester, IN 46975-0524 105 North Detroit Street 801 Main St., 2nd Floor, P.O. Box 125
P.O. Box 85 (574) 223-4824 LaGrange, IN 46761-1801 Petersburg, IN 47567-1298 UNION
Nashville, IN 47448 (260) 499-6392 (812) 354-6025 Union Co. Circuit Court Clerk
(812) 988-5510 GIBSON 26 West Union Street
Gibson Co. Circuit Court Clerk LAKE PORTER Liberty, IN 47353-1396
CARROLL 101 N. Main St. Lake Co. Board of Elections and Registration Porter Co. Board of Elections and Voter (765) 458-6121
Carroll County Voter Registration Princeton, IN 47670 2293 N. Main Street, A-205 Registration
101 W. Main Street, Ste. 206 (812) 385-2541 Crown Point, IN 46307 155 Indiana Avenue, Ste. 105 VANDERBURGH
Delphi, IN 46923 (219) 755-3795 Valparaiso, IN 46383-5555 Vanderburgh Co. Voter Registration
(765) 564-6795 GRANT (219) 465-3485 Civic Center Complex, Room 214
Grant Co. Circuit Court Clerk LAPORTE 1 NW Martin Luther King Jr. Blvd.
CASS Courthouse Suite B-9 LaPorte Co. Board of Voter Registration POSEY Evansville, IN 47708-1828
Cass Co. Circuit Court Clerk 101 E. 4th Street 813 Lincolnway, Suite 103 Posey Co. Circuit Court Clerk (812) 435-5222
200 Court Park, Room 407 Marion, IN 46952-4055 LaPorte, IN 46350-3401 300 Main Street, Rm 115
Logansport, IN 46947- 1392 (765) 664-9880 (219) 326-6808 EXT 2250 Mt. Vernon, IN 47620 VERMILLION
(574) 753-7870 (812) 838-1339 Vermillion Co. Circuit Court Clerk
GREENE LAWRENCE 255 S. Main Street, Room 304
CLARK Greene County Voter Registration Lawrence Co. Circuit Court Clerk PULASKI P.O. Box 10
Clark Co. Circuit Court Clerk 1 East Main St 916 15th Street, Room 11 Pulaski Co. Circuit Court Clerk Newport, IN 47966
501 E. Court Avenue, Room 139 Bloomfield, IN 47424 Bedford, IN 47421-3800 112 E. Main Street, Room 230 (765) 492-5350
Jeffersonville, IN 47130-4090 (812) 384-2015 (812) 277-2036 Winamac, IN 46996-1394
(812) 285-6329 (574) 946-4401 VIGO
HAMILTON MADISON Vigo Co. Board of Voter Registration
CLAY Hamilton County Voter Registration Office Madison Co. Board of Voter Registration PUTNAM Courthouse, Room 3
Clay Co. Circuit Court Clerk 1 Hamilton County Square, Suite 13 16 East 9th Street, Suite 208 Putnam County Voter Registration 33 South 3rd Street
609 E. National Ave., Room 211 Noblesville, IN 46060-2219 Anderson, IN 46016-1588 1 W. Washington St., Room 21, P.O. Box 546 Terre Haute, IN 47808-3472
Brazil, IN 47834-0033 (317) 776-9632 (765) 641-9657 Greencastle, IN 46135-0546 (812) 462-3393
(812) 448-9023 (765) 655-1538
HANCOCK MARION WABASH
CLINTON Hancock County Voter Registration Marion Co. Board of Voter Registration RANDOLPH Wabash County Voter Registration
Clinton Co. Circuit Court Clerk 9 East Main Street, Room 213 200 East Washington, W131 Randolph Co. Circuit Court Clerk 69 West Hill Street
265 Courthouse Square Greenfield, IN 46140-2320 Indianapolis, IN 46204 100 S. Main St. Room 201 Wabash, IN 46992-3151
Frankfort, IN 46041-1993 (317) 477-1171 (317) 327-5040 Winchester, IN 47394 (260) 563-0661 EXT 1238
(765) 659-6337 (765) 584-4717
HARRISON MARSHALL WARREN
CRAWFORD Harrison Co. Circuit Court Clerk Marshall Co. Circuit Court Clerk RIPLEY Warren County Voter Registration
Crawford Co. Circuit Court Clerk Courthouse, Room 203 211 West Madison Street Ripley Co. Circuit Court Clerk 125 N. Monroe Street, Suite 11
715 Judicial Plaza Drive 300 North Capitol Avenue Plymouth, IN 46563-1762 115 N. Main Street Williamsport, IN 47993-1198
P.O. Box 375 Corydon, IN 47112-1155 (574) 935-8713 P.O. Box 177 (765) 762-2834
English, IN 47118 (812) 738-8790 Versailles, IN 47042
(812) 338-2565 MARTIN (812) 689-4783 WARRICK
HENDRICKS Martin Co. Circuit Court Clerk Warrick Co. Election Office
DAVIESS Hendricks Co. Voter Registration Office 129 Main Street RUSH 1 County Square, Suite 220
Daviess County Voter Registration Office Election Supervisor P.O. Box 120 Rush Co. Circuit Court Clerk Boonville, IN 47601-1594
200 East Walnut, P.O. Box 739 355 S. Washington St. #120 Shoals, IN 47581 101 East 2nd Street, Rm 209 (812) 897-6161
Washington, IN 47501-0739 Danville, IN 46122 (812) 247-3651 Rushville, IN 46173-0429
(812) 254-8679 (317) 745-9249 (765) 932-2086 WASHINGTON
MIAMI Washington County Justice Center
DEARBORN HENRY Miami County Voter Registration SCOTT 801 S Jackson St
Dearborn County Election Clerk Henry County Voter Registration Office 25 N. Broadway, Room 108 Scott County Voter Registration Salem, IN 47167-2098
165 Mary Street 1215 Race St, Suite 130 Peru, IN 46970-0184 1 East McClain Avenue, Suite 120 (812) 883-5748
Lawrenceburg, IN 47025 New Castle, IN 47362 (765) 472-3995 Scottsburg, IN 47170
(812) 537-8867 (765) 529-9310 (812) 752-8420 WAYNE
MONROE Wayne Co. Circuit Court Clerk
DECATUR HOWARD Monroe Co. Voter Registration SHELBY 301 East Main Street
Decatur Co. Circuit Court Clerk Howard County Voter Registration 401 W. 7th Street, Suite 100 Shelby Co. Circuit Court Clerk Richmond, IN 47374
150 Courthouse Square, Suite 244 104 N Buckeye Street Room 104B Bloomington, IN 47404 407 S. Harrison Street (765) 973-9304
Greensburg, IN 47240-2080 Kokomo, IN 46901 (812) 349-2690 P.O. Box 198
(812) 663-8223 (765) 456-2219 Shelbyville, IN 46176-0198 WELLS
MONTGOMERY (317) 392-6324 Wells Co. Clerk
DEKALB HUNTINGTON Montgomery Co. Circuit Court Clerk 102 W. Market St., Suite 201
DeKalb Co. Circuit Court Clerk Huntington Co. Circuit Court Clerk 100 East Main Street, Room 203 SPENCER Bluffton, IN 46714-2091
100 S. Main Street 201 North Jefferson Street P.O. Box 768 Spencer County Voter Registration (260) 824-6479
P.O. Box 230 P.O. Box 228 Crawfordsville, IN 47933-0768 200 Main Street, Ste. 5
Auburn, IN 46706-0230 Huntington, IN 46750 (765) 364-6437 P.O. Box 523 WHITE
(260) 925-9787 (260) 358-4820 Rockport, IN 47635 White Co. Circuit Court Clerk
MORGAN (812) 649-6017 110 Main Street
DELAWARE JACKSON Morgan County Election Division P.O. Box 350
Delaware Co. Voter Registration Jackson Co. Voter Registration 180 S. Main St., Suite 1 ST. JOSEPH Monticello, IN 47960-0350
100 West Main Street, Room 104 109 S Sugar St, Suite 130 Martinsville, IN 46151-1556 St. Joseph Co. Board of Voter Registration (574) 583-1531
Muncie, IN 47305-2836 Brownstown, IN 47220 (765) 342-1029 City-County Building, 4th Floor
(765) 747-7712 (812) 358-6120 227 West Jefferson Blvd. WHITLEY
NEWTON South Bend, IN 46601-1871 Whitley Co. Circuit Court Clerk
JASPER Newton Co. Circuit Court Clerk (574) 235-9520 101 W. Van Buren Street
Jasper Co. Circuit Court Clerk P.O. Box 49 Columbia City, IN 46725-2087
115 W. Washington Kentland, IN 47951-0049 (260) 248-3164
Rensselaer, IN 47978 (219) 474-6081
(219) 866-4929