Indiana Code
Chapter 15. Registration Procedures at Public Assistance Agencies
3-7-15-5. Requirements of Registration Form

Sec. 5. The registration form prescribed under section 4 of this chapter must meet the following requirements:
(1) The form must be equivalent to the mail registration form prescribed by the election division under IC 3-7-31 and in compliance with 52 U.S.C. 20506(a)(6)(A)(ii).
(2) The form must include a statement that does the following:
(A) Sets forth each eligibility requirement for registration (including citizenship).
(B) Contains an attestation that the applicant meets each of the eligibility requirements.
(C) Requires the signature of the applicant, under penalty of perjury, and the date the form was signed.
(3) The form must include the following as provided in 52 U.S.C. 20506(a)(6)(B):
(A) A question reading "If you are not registered to vote where you live now, would you like to apply to register to vote here today?".
(B) A statement reading "Applying to register or declining to register to vote will not affect the amount of assistance that you will be provided by this agency.".
(C) Boxes for the applicant to check to indicate whether the applicant would like to register or declines to register to vote.
(D) A statement in close proximity to the boxes and in prominent type: "IF YOU DO NOT CHECK EITHER BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER TO VOTE AT THIS TIME.".
(E) A statement reading "If you would like help in filling out the voter registration application form, we will help you. The decision whether to seek or accept help is yours. You may fill out the application form in private.".
(F) A statement reading "If you believe that someone has interfered with your right to register or to decline to register to vote, or your right to choose your political party or other political preference, you may file a complaint with (insert the title, address, and telephone number of the NVRA official). If you want you may first try to solve the problem by filing a complaint with the county voter registration office of the county where the violation occurred.".
As added by P.L.12-1995, SEC.24. Amended by P.L.3-1997, SEC.57; P.L.128-2015, SEC.46; P.L.169-2015, SEC.20.