CALIFORNIA VOTER PRE-REGISTRATION RECEIPT

RECEIVED
AFFIDAVIT NUMBER
05/03/2020
11:20:32 65CB499284

Print, Sign and Mail

• Print and sign your application. You must fold and tape the form for mailing. Put the
county elections office address on the outside. Place a first-class stamp in the box in the
upper-right corner.

Important Notices
• This page is your receipt. Keep it until you get a Voter Notification Card in your mail.
If you have any questions, please contact your county elections office and give the
affidavit number above.
• The law protects your voter registration information against commercial use. Report any
problems to the Secretary of State’s Voter Hotline at (800) 345-VOTE (8683) or email
elections@sos.ca.gov.

DEVA MARIE PROTO

SONOMA COUNTY CLERK, REGISTRAR OF
VOTERS
PO BOX 11485
SANTA ROSA, CA 95406-1485

707-565-6800
rov-info@sonoma-county.org
 CALIFORNIA VOTER PRE-REGISTRATION APPLICATION
SONOMA COUNTY 65CB499284
PO BOX 11485
SANTA ROSA, CA 95406-1485
707-565-6800
*65CB499284*

NAME & ADDRESS CALIFORNIA ID SSN4 DATE OF BIRTH

4040 11/05/2002
Lopez, Bryan Y
415 N CLOVERDALE BLVD APT A
APT A PHONE NUMBER PLACE OF BIRTH
CLOVERDALE, CA 95425 707-624-3190 CALIFORNIA

EMAIL
Bryan.lopezchs2020@gmail.com
MAILING ADDRESS LANGUAGE
ENGLISH
PERMANENT VOTE-BY-MAIL VOTER
No
RECEIVE STATE VOTER INFORMATION GUIDE BY MAIL
BEFORE EACH STATEWIDE ELECTION
Yes
IF NO ADDRESS, DESCRIPTION
RECEIVE COUNTY VOTER INFORMATION GUIDE BY
MAIL BEFORE EACH STATEWIDE ELECTION
Yes

ELECTRONIC NOTIFICATION EMAIL

PRIOR PRE-REGISTRATION (IF APPLICABLE)
VOLUNTEER

DID SOMEONE HELP YOU FILL OUT THIS FORM? POLITICAL PARTY
NO PARTY PREFERENCE
YES NO
ETHNICITY/RACE
HISPANIC

I am a U.S. citizen.

I am 16 or 17 years old and I would like to pre-register to vote.

READ, SIGN AND DATE BELOW

I declare under penalty of perjury under the laws of the State of California that:
• I am a U.S. citizen and resident of California and at least 16 years old.
• I am not currently in a state or federal prison or on parole for the conviction of a felony.
• I am not currently found mentally incompetent to vote by a court.
• I understand that it is a crime to intentionally provide incorrect information on this form.
• The information on this form is true and correct.

MAIL IMMEDIATELY 05/03/2020

SIGNATURE DATE (MM/DD/YYYY)

 FOR OFFICIAL USE ONLY

FIRST CLASS
STAMP
NECESSARY
FOR
MAILING

DEVA MARIE PROTO

SONOMA COUNTY CLERK, REGISTRAR OF
VOTERS
PO BOX 11485
SANTA ROSA, CA 95406-1485

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