Louisiana Voter Registration Application

(LA-VRA - Rev. 6/19)

SEE THE OTHER SIDE OF THIS PAGE FOR INSTRUCTIONS



QUESTIONS? - Call your parish Registrar of Voters Office or call the

Secretary of State at 1-800-883-2805 or (225) 922-0900.

OFFICIAL USE ONLY:

WD: ___________________ PCT: ___________________ REG. TYPE: ___________________ IN/OUT: ___________________ REG # ___________________

Provided by the Louisiana Secretary of State

Approved by the Louisiana Attorney General

LA-VRA - Rev. 6/19

Please print clearly in ink, preferably black.

Reason for Application:



New Voter Registration



Updating Voter Registration

* If you do not have a LA driver’s license or LA special ID, the last four digits of your social security number are required if you have one. Full SSN is preferred but optional.

Note: If you decline to register to vote, this fact will remain confidential and will be used only for voter registration purposes. If you register to vote, the office where your application was submitted

will remain confidential and will be used only for voter registration purposes. You may request a copy of your voter registration form at any time from the registrar of voters.

Eligibility 1.

Are you a citizen of the United States of America?



Yes



If you checked ‘No’ in response to either of these questions, do not complete this form. You

are not eligible to vote at this time.

(Please see application instructions for information regarding eligibility to register

prior to age 18.)

Will you be 18 years of age on or before election day?

 Yes 

Name 2.

LAST NAME:

FIRST NAME:

FULL MIDDLE OR

MAIDEN NAME:

SUFFIX (Sr., Jr., II):

Residence

Address

here you live and

claim homestead

exemption, if any)

HOUSE # &

STREET (NO P.O. BOX):

UNIT/APT #:

Give Location (If Necessary)

CITY/TOWN:

STATE

ZIP CODE:

Mailing

Address

(If different from

Residence Address)

 Check if no postal service at your residence address above and supply mailing address here.

HOUSE # &

STREET/P.O. BOX:

UNIT/APT #:

CITY/TOWN:

STATE:

ZIP CODE:

Date of Birth 4.

_______/_______/_________

MM DD YYYY

*SSN

___________ - ________ - ____________

XXX XX XXXX

6. Sex

 M

 F

Race

(Optional)

 WHITE  BLACK  ASIAN

 HISPANIC  AMERICAN INDIAN

 OTHER ________________________

Party

Affiliation

 DEMOCRAT  GREEN  INDEPENDENT

 LIBERTARIAN  REPUBLICAN  NO PARTY

 OTHER

(Specify) ____________________________

Place

of Birth

CITY/TOWN:

STATE:

PARISH/COUNTY:

COUNTRY:

Mother’s

Maiden Name

10.

____________________________

11. Email

_______________________________

12.

Phone

Home: (________) _________ - ___________

Other: (________) _________ - ___________

LA DL/ID

Card #

13.

_________________________________________

 I do not have a LA DL/ID card.

14.

Do you need

assistance in

voting?

 No

 Yes, Reason: _____________________________________________

Last

Residence

Address

15.

HOUSE #

& STREET:

16.

Place

of Last

Registration

STATE:

17.

Former

Registered

Name, if any

CITY:

STATE:

PARISH/

COUNTY:

Affirmation

and Signature

(Read and sign or

make your mark.)

18.

I do hereby solemnly swear or affirm that I am a United States citizen, that I am of eligible age to register to vote, that I have not been incarcerated pursuant to an order of

imprisonment for conviction of a felony within the past five years, nor am I under an order of imprisonment for a felony offense of election fraud or other election offense

pursuant to R.S. 18:1461.2, that I am not currently under a judgment of fu

ll interdiction or limited interdiction where my right to vote has been suspended, that I am a bona

fide resident of this state and parish, and that the facts given by me on this application are true to the best of my knowledge and belief. If I have provided false information,

I may be subject to a fine of not more than $2,000 ($5,000 for subsequent offense) or imprisonment for not more than 2 years (5 years for subsequent offense), or both.

Applicant

Signature:



Date:

Witnesses

(If your signature is

a mark, you must

have two witnesses

sign.)

19.

Witness #1

Signature:



Witness #1

Print Name:

Witness #2

Signature:



Witness #2

Print Name:

OFFICIAL USE ONLY

 New Registration Updated Registration:  Address Change  Name Change  Party Change  Change to Assistance in Voting  Other

REMARKS:

CIRCLE ONE:

PA MV RG SDA SS (Disability) Received by: __________________________________________________ Date: _________________________

Louisiana Voter Registration Application

(LA-VRA - Rev. 6/19)

QUESTIONS? - Call your parish Registrar of Voters Office or call

the Secretary of State at 1-800-883-2805 or (225) 922-0900.

Provided by the Louisiana Secretary of State

Approved by the Louisiana Attorney General

LA-VRA - Rev. 6/19

APPLICATION INSTRUCTIONS

USE THIS LOUISIANA VOTER REGISTRATION APPLICATION TO: 1) register to vote; 2) change your address; 3) request a name change; 4) change party affiliation; or

5) request assistance in voting.

TO REGISTER AND BE ELIGIBLE TO VOTE, AN APPLICANT MUST: 1) be a U.S. citizen; 2) be at least 17 years old (16 years old if registering to vote in person at the

Registrar’s Office or with an application for a Louisiana driver’s license) but must be 18 years old before actually voting; 3) not be under an order of imprisonment for

conviction of a felony or, if under such an order, not have been incarcerated pursuant to the order within the last five years and not be under an order of imprisonment related

to a felony conviction for election fraud or any other election offense pursuant to R.S. 18:1461.2; 4) not be under a judgment of full interdiction or limited interdiction where

your right to vote has been suspended; 5) reside in the state and parish in which you seek to register and vote.

Instructions: the gray section numbers on this page correspond to the gray section numbers on the application.

Reason for Application: Check “New Voter Registration” if this is a first time registration or if a new registration in a new parish after moving. Check “Updating Voter

Registration” if you are making any change to your present registration. If new registration, fill out the form completely.

Eligibility - Federal law requires you to affirm that you are a citizen of the United States of America and that you will be 18 years of age on or before the election day in

which you are eligible to vote. If you checked ‘No’ in response to either of these questions, do not complete this form. You are not eligible to vote at this time. If you are

registering as a 16 or 17 year old, you may check “Yes” because you will not be allowed to vote until you are 18.

Name - You must provide your full name. Do not use nicknames or initials for middle or maiden name. If this application is for a change of name, please also complete

section 17: “Former Registered Name.”

Residence Address - “Residence Address” means the address (number, street, city, state, and zip) where you live and are registering to vote. Residence address must be

the address where you claim homestead exemption, if any, except for a resident in a nursing home or veterans’ home who may choose

to use the address of the nursing

home or veterans’ home or the home where they have a homestead exemption. A college student may elect to use their home address or their address at school

while

attending. Do not use a post office box for your “Residence Address.” If you use a rural route and box number, you may draw a map in box labeled “Give Location”

provide the exact location. Write in the names of the crossroads (streets) nearest to residence. Draw an X to show residence. Use a dot to show any scho

ols, churches,

stores, or landmarks near residence and write the name of the landmark.

Mailing Address - If you check that you do not receive postal service at your residence address, you must provide your mailing address (number, street, city, state, and

zip). Otherwise, a mailing address may be provided and you may use a post office box for a mailing address.

Birthdate - Print your date of birth. The month and day of your birth remains confidential by law.

Social Security Number - If you do not have a LA driver's license or LA special identification card, you must provide the last four digits of your social security number, if

issued. The full social security number is preferred and may be provided on a voluntary basis and will be kept confidential. If you were not issued a social security number

or a LA DL or ID and this form is submitted by mail, and you are registering to vote for the first time, in order to avoid additional identification requirements for first time

voters you must attach one or more documents to prove your identity, residence, and date of birth. Documents may be: a) a copy of current and valid photo identification

and/or b) a copy of a current utility bill, bank statement, government check, paycheck, or other government document.

Your SSN remains confidential and is only used for

registration purposes.

Sex - Check male or female (for statistical purposes only).

Race - Race/Ethnic origin is optional (for statistical purposes only).

Party Affiliation - If you are registering for the first time, you may choose a party affiliation of Democrat, Green, Independent, Libertarian, or Republican parties. You may

specify any other party affiliation by checking “other” and then listing the party with which you wish to affiliate. If you do not want to register with a political par

ty affiliation

check “No Party,” or if you do not complete this section, your party affiliation will be listed as “No Party.” If you are already registered with a party affili

ation and no political

party change is being made with this application, you may leave this section blank or re-enter your political party affiliation.

Place of Birth - Print the city/town, parish/county, state, and country of your birth place (for statistical purposes only).

10.

Mother’s Maiden Name - Print your mother’s maiden name, which is her last name at her birth. If unknown, write “unknown.”

11.

Email - Give your email address for election officials to contact you if there is a problem with your registration. Email addresses are protected from disclosure by law and

are for official use only.

12.

Phone - Give your phone numbers for election officials to contact you if there is a problem with your registration. Phone numbers are optional and a public record unless

you make a request for your phone numbers to be kept confidential by election officials.

13.

LA DL/ID Card # - Print your LA driver’s license or LA special identification card number, if issued. If you do not have one, check “I do not have a LA DL/ID card.” This ID

number remains confidential and is for official use only.

14.

Assistance in Voting Needed? - Indicate if you will need assistance in voting by checking either the “No” or “Yes” box. If “Yes,” write the reason for needing assistance. The

registrar of voters in your parish may contact you for proof of disability.

15.

Place of Last Residence - Print the address (number, street, city, and state) of your prior residence, if different from residence address in section 3 or write “Same.”

16.

Place of Last Registration - Print the state and parish (or county) of your last registration if you were registered in another parish or state prior to completing this

application. Important: Contact the local election office in your prior state and cancel your prior registration. Registering in Louisiana does not automatic

ally cancel or

transfer your voter registration from another state.

17.

Former Registered Name - If you are using this application to make a name change to your registration, print your former registered name (name you are changing) in this

section. If name changed by court order, provide a copy of the order with this application.

18.

Affirmation and Signature - Read the affirmation and sign your full name or make your mark and print the date this application was signed and completed. If assistance in

registering is being provided, make sure the applicant understands what they are affirming and that they meet the requirements to register to vote.

19.

Witnesses - If you are unable to sign your name, you may make your mark, but it must be witnessed by two people or it is not valid.

Mailing Instructions - If returned by mail, place in an envelope and mail to your Registrar of Voters Office. You can find your registrar of voters mailing address on the Registrar of

Voters Address Page, by visiting our website at www.geauxvote.com

or by calling toll free at 1-800-883-2805. Your application or envelope must be postmarked 30 days prior to the first

election in which you seek to vote.

Online Voter Registration - Voter registration is also available at www.geauxvote.com and you may register online before the 20

day prior to the election. Please call your registrar of

voters if you do not receive your voter information card two weeks after registering.

Louisiana Registrars of Voters Address Page

(Rev. 10/22)

QUESTIONS? - Call your parish Registrar of Voters Office or call

the Secretary of State at 1-800-883-2805 or (225) 922-0900.

Provided by the Louisiana Secretary of State

Louisiana Registrars of Voters Address Page - Rev. 10/22

LOUISIANA REGISTRARS OF VOTERS OFFICE ADDRESSES

ACADIA

568 NW Court Circle

Crowley, LA 70526-4363

(337) 788-8841

EAST BATON ROUGE

222 St. Louis St., Rm. 201

Baton Rouge, LA 70802-5860

(225) 389-3940

MADISON

100 N. Cedar St., Rm. #5

Tallulah, LA 71282-3892

(318) 574-2193

ST. LANDRY

P.O. Box 818

Opelousas, LA 70571-0818

(337) 948-0572

ALLEN

P.O. Box 150

Oberlin, LA 70655-0150

(337) 639-4966

EAST CARROLL

P.O. Box 708

Lake Providence, LA 71254-0708

(318) 559-2015

MOREHOUSE

129 N. Franklin St., Ste. 1

Bastrop, LA 71220-3815

(318) 281-1434

ST. MARTIN

415 Saint Martin St.

St. Martinville, LA 70582-4549

(337) 394-2204

ASCENSION

828 S. Irma Blvd., Rm. 205

Gonzales, LA 70737-3631

(225) 621-5780

EAST FELICIANA

P.O. Box 488

Clinton, LA 70722-0488

(225) 683-3105

NATCHITOCHES

P.O. Box 677

Natchitoches, LA 71458-0677

(318) 357-2211

ST. MARY

500 Main St., Courthouse, Rm. 301

Franklin, LA 70538-6144

(337) 828-4100, ext. 360

ASSUMPTION

P.O. Box 578

Napoleonville, LA 70390-0578

(985) 369-7347

EVANGELINE

200 Court St., Ste. 102

Ville Platte, LA 70586-4463

(337) 363-5538

ORLEANS

1300 Perdido St., Rm. 1W24

New Orleans, LA 70112-2127

(504) 658-8300

ST. TAMMANY

701 N. Columbia St.

Covington, LA 70433-2709

(985) 809-5500

AVOYELLES

312 N. Main St., Ste. E

Marksville, LA 71351-2409

(318) 253-7129

FRANKLIN

6560 Main St.

Winnsboro, LA 71295-2750

(318) 435-4489

OUACHITA

1650 Desiard St., Rm. 125

Monroe, LA 71201

(318) 327-1436

TANGIPAHOA

P.O. Box 895

Amite, LA 70422-0895

(985) 748-3215

BEAUREGARD

P.O. Box 952

DeRidder, LA 70634-0952

(337) 463-7955

GRANT

200 Main St., Courthouse Bldg.

Colfax, LA 71417-1828

(318) 627-9938

PLAQUEMINES

P.O. Box 989

Port Sulphur, LA 70083-0989

(504) 934-3620

TENSAS

P.O. Box 183

St. Joseph, LA 71366-0183

(318) 766-3931

BIENVILLE

P.O. Box 697

Arcadia, LA 71001-0697

(318) 263-7407

IBERIA

300 S. Iberia St., Ste. 110

New Iberia, LA 70560-4543

(337) 369-4407

POINTE COUPEE

P.O. Box 520

New Roads, LA 70760-0520

(225) 638-5537

TERREBONNE

8026 Main St., Ste. 101

Houma, LA 70360

(985) 873-6533

BOSSIER

P.O. Box 635

Benton, LA 71006-0635

(318) 965-2301

IBERVILLE

P.O. Box 554

Plaquemine, LA 70765-0554

(225) 687-5201

RAPIDES

701 Murray St.

Alexandria, LA 71301-8099

(318) 473-6770

UNION

P.O. Box 235

Farmerville, LA 71241-0235

(318) 368-8660

CADDO

P.O. Box 1253

Shreveport, LA 71163-1253

(318) 226-6891

JACKSON

500 E. Court St., Rm. 102

Jonesboro, LA 71251-3400

(318) 259-2486

RED RIVER

P.O. Box 432

Coushatta, LA 71019-0432

(318) 932-5027

VERMILION

100 N. State St., Ste.120

Abbeville, LA 70510

(337) 898-4324

CALCASIEU

1000 Ryan St., Rm. 7

Lake Charles, LA 70601-5250

(337) 721-4000

JEFFERSON

P.O. Box 10494

Jefferson, LA 70181-0494

(504) 736-6191

RICHLAND

P.O. Box 368

Rayville, LA 71269-0368

(318) 728-3582

VERNON

P.O. Box 626

Leesville, LA 71496-0626

(337) 239-3690

CALDWELL

P.O. Box 1107

Columbia, LA 71418-1107

(318) 649-7364

JEFFERSON DAVIS

302 N. Cutting Ave.

Jennings, LA 70546-5361

(337) 824-0834

SABINE

400 Capitol St., #107

Many, LA 71449-3099

(318) 256-3697

WASHINGTON

900 Washington St.

Franklinton, LA 70438-1719

(985) 839-7850

CAMERON

P.O. Box 1

Cameron, LA 70631-0001

(337) 775-5493

LAFAYETTE

1010 Lafayette St., Ste. 313

Lafayette, LA 70501-6885

(337) 291-7140

ST. BERNARD

8201 W. Judge Perez Dr.

Chalmette, LA 70043-1696

(504) 278-4231

WEBSTER

P.O. Box 674

Minden, LA 71058-0674

(318) 377-9272

CATAHOULA

P.O. Box 215

Harrisonburg, LA 71340-0215

(318) 744-5745

LAFOURCHE

307 W. 4th St.

Thibodaux, LA 70301-3105

(985) 447-3256

ST. CHARLES

P.O. Box 315

Hahnville, LA 70057-0315

(985) 783-5120

WEST BATON ROUGE

P.O. Box 31

Port Allen, LA 70767-0031

(225) 336-2421

CLAIBORNE

507 W. Main St., Ste. 1

Homer, LA 71040-3914

(318) 927-3332

LASALLE

P.O. Box 2439

Jena, LA 71342-2439

(318) 992-2254

ST. HELENA

P.O. Box 543

Greensburg, LA 70441-0543

(225) 222-4440

WEST CARROLL

P.O. Box 71

Oak Grove, LA 71263-0071

(318) 428-2381

CONCORDIA

4001 Carter St., Ste. K

Vidalia, LA 71373-3021

(318) 336-7770

LINCOLN

100 W. Texas Ave., #10

Ruston, LA 71270-4463

(318) 251-5110

ST. JAMES

P.O. Box 179

Convent, LA 70723-0179

(225) 562-2330

WEST FELICIANA

P.O. Box 2490

St. Francisville, LA 70775-2490

(225) 635-6161

DESOTO

104 Crosby St.

Mansfield, LA 71052-2046

(318) 872-1149

LIVINGSTON

P.O. Box 968

Livingston, LA 70754-0968

(225) 686-3054

ST. JOHN

1811 W. Airline Hwy.

LaPlace, LA 70068-3344

(985) 359-0179

WINN

119 W. Main St., Rm. 105

Winnfield, LA 71483-3238

(318) 628-6133

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