Utah Code § 20A-6-105
"AFFIRMATION
Are you a citizen of the United States of America? Yes No
Will you be 18 years old on or before election day? Yes No
If you checked "no" in response to either of the two above questions, do not complete this form.
Name of Voter _________________________________________________________
First Middle Last
Driver 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
______________________________________________________________________
City County State Zip Code
Telephone Number (optional) ______________________________________________
Email Address (optional)__________________________________________________
Last four digits of Social Security Number ____________________________
Last former address at which I was registered to vote (if known)
______________________________________________________________________
City County State Zip Code
Voting 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; and
Subject 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 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 INFORMATION
Voter registration records contain some information that is available to the public, such as your name and address, some information that is available only to government entities, and some information that is available only to certain third parties in accordance with the requirements of law.
Your driver license number, identification card number, social security number, email address, full date of birth, and phone number are available only to government entities. Your year of birth is available to political parties, candidates for public office, certain third parties, and their contractors, employees, and volunteers, in accordance with the requirements of law.
You may request that all information on your voter registration records be withheld from all persons other than government entities, political parties, candidates for public office, and their contractors, employees, and volunteers, by indicating here:
_____ Yes, I request that all information on my voter registration records be withheld from all persons other than government entities, political parties, candidates for public office, and their contractors, employees, and volunteers.
REQUEST FOR ADDITIONAL PRIVACY PROTECTION
In addition to the protections provided above, you may request that identifying information on your voter registration records be withheld from all political parties, candidates for public office, and their contractors, employees, and volunteers, by submitting a withholding request form, and any required verification, as described in the following paragraphs.
A person may request that identifying information on the person's voter registration records be withheld from all political parties, candidates for public office, and their contractors, employees, and volunteers, by submitting a withholding request form with this registration record, or to the lieutenant governor or a county clerk, if the person is or is likely to be, or resides with a person who is or is likely to be, a victim of domestic violence or dating violence.
A person may request that identifying information on the person's voter registration records be withheld from all political parties, candidates for public office, and their contractors, employees, and volunteers, by submitting a withholding request form and any required verification with this registration form, or to the lieutenant governor or a county clerk, if the person is, or resides with a person who is, a law enforcement officer, a member of the armed forces, a public figure, or protected by a protective order or a protection order.
CITIZENSHIP AFFIDAVIT
Name:
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 Applicant
In 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."
Utah Code § 20A-6-105