721—23.3 (75GA,ch1169) Declination forms. The offer of voter registration shall include a declination form in substantially the following form:
STATE OF IOWA
Voter Registration Information
You can apply to register to vote when you apply for assistance. This agency is required to offer you the chance to register to vote.
Registration Rules—You must be registered before you can vote in an election.
To register to vote in Iowa you must—
	  ● 	 be a citizen of the United States
	  ● 	 be a resident of Iowa
	  ● 	 be at least 17½ years old (you must be 18 to vote)
	  ● 	 not have been convicted of a felony (or have had your rights restored)
	  ● 	 not currently be judged “mentally incompetent” by a court
	  ● 	 give up the right to vote in any other place.
Help: If you would like help in filling out the voter registration form, we will help you. The decision whether to seek or accept help is yours. You may fill out the application form in private.
Benefits: Applying to register or declining to register to vote will not affect the amount of assistance that you will be provided by this agency.
Privacy: If you register to vote, the name of the office where you turn in the form will be kept private. If you do not register to vote, this fact will be kept private. This information will be used only for voter registration purposes.
Complaints: If you believe that someone has interfered with your right to
	  ● 	 register or to decline to register to vote,
	  ● 	 privacy in deciding whether to register,
	  ● 	 privacy in applying to register to vote,
	  ● 	 choose your own political party or other political preference,
you may file a complaint with:
Voter Registration Commission
Level B
Hoover State Office Building Telephone:
Des Moines, Iowa 50319 (515)281-5781
If you are not registered to vote where you live now, would you like to apply to register to vote here today?
□ Yes, I want to register to vote.
□ No, I do not want to register to vote.
If you do not check either box, you will be considered to have decided not to register to vote at this time.

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