WARNING: Failure to respond to this mailing shall result in removal from the active voting list and may result in removal from the voter registration rolls. YOU CANNOT REGISTER TO VOTE OR CHANGE YOUR PARTY AFFILIATION ON THIS FORM. Please call the clerk’s office to register to vote or change affiliations.

* 1. Please enter 12 digit number found in upper right hand corner, beneath bar code on mailed out census form:

* 2. Name of person completing this form:

* 3. Current Physical Address: (Non-PO Address)

* 4. Is all information on mailed out census form correct? If yes, please skip to Question 8.

* 5. Other than residents listed as living at this address, are there any others that should be included? (separate names with a comma, include dates of birth)

* 6. Are there any residents listed on your form who do not live at this address? If so, please give their names and new addresses, if known. (please separate information with commas)

* 7. Please make any other changes to the census form here

* 8. Your residential address and mailing address January 1, 2015 (if different)

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