Ill. Admin. Code tit. 26, pt. 216, exh. H
Mandated
December, 1995
SBE No. C-6
ADDRESS CORRECTION FOR FAIL-SAFE VOTER
[] FEDERAL BALLOT ONLY
* Voters who change residence to another address within Election Authority's jurisdiction.
* Voting in former residence polling place or when applying for absentee ballot.
Social Security Number (last four numbers: ______________________________
Date of Birth: ________________________
Voter's Full Name (Please Print):
__________________________________________________________________
Current Address:
__________________________________________________________________
City/Village ___________________________ Zip Code _________________
Former Address:
__________________________________________________________________
City/Village ___________________________ Zip Code _________________
____________________________________
DateSignature of Voter or Mark
Ill. Admin. Code tit. 26, pt. 216, exh. H