Full Text
Voter Registration Cancellation/Removal Form Please remove the following name from the list of registered voters in the State of Georgia due to the following reason: (Select One) Voter has moved out of state. New State of Residence: Voter no longer wishes to be registered to vote in the State of Georgia. Voter is deceased. Date of Death (MM/DD/YYYY): Was there an obituary posted in the newspaper? Yes No Full Name: Former Georgia Address: Former County in Georgia: Date of Birth (MM/DD/YYYY): I, , swear or affirm that the voter registration information provide above is true and accurate to the best of my knowledge. I hereby request the Georgia voter registration be cancelled for this voter, effective as of the date this form is received by the voter’s County Board of Elections and Registration. I understand that this voter will no longer be eligible to vote in the State of Georgia unless they re-apply for registration. Signature: Date: If voter is deceased, relationship to deceased voter: THIS VOTER WILL NOT BE REMOVED UNLESS THIS FORM IS SIGNED BY THE VOTER OR RELATIVE OF DECEASED VOTER. Mail, fax, or email to the voter’s Georgia County Elections office or the Georgia Secretary of State office. County Elections & Registration Office Contact Information countyregistrars.do Georgia Secretary of State Contact Information Email: [EMAIL REDACTED] Fax: (404)463-5231 Attn: Elections Cancellation 2 Martin Luther King Jr. Dr. S.E. Suite 802, West Tower Atlanta, GA 30334 OFFICE USE ONLY Date Received: VR Number: