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2. First Name
3. Last Name
5. Email*

   Please provide the email you want the Already Voted List sent to.

6. Phone Number
8. Organization (if relevant)
10. Address1
12. Address2
14. City
15. State
16. Zip
18. Which of the following applies to you?*

    1. General Public
    2. Official Party Affiliation
    3. Candidate
    4. Campaign Representative
19. Which party or candidate (if relevant)?*

    If you selected General Public, write "none."

21. I understand that private voter data is a different classification than withheld voter data and that withheld voter data will not be included in my voter file (20A-2-104).*

    1. Yes
23. I understand that only Qualified Individuals are eligible to request and possess private donor data (20A-2-104), and that members of the General Public will only receive public donor data.*

    1. Yes
25. I understand that I will only use this information for political purposes and in accordance with state law and will not disclose any information received to parties that are not qualified under 20A-2-104.*

    1. Yes
27. I understand that making false statements in this document is punishable by law under UCA 76-8-504.*

    1. Yes
29. I understand that an individual who obtains a voter registration record under false pretenses or provides or uses voter registration information that is obtained from the list of registered voters in a manner prohibited by law, is guilty of a Class B misdemeanor.*

    1. Yes
31. I understand that Grand County must receive payment before releasing the requested information.*

    1. Yes
33. By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.*

    1. I agree
35. Electronic Signature*

37. The $15 fee can be paid over the phone by calling our office at 435-259-1321, or stopping by the Clerk's Office during business hours. Credit/debit card transactions will incur a 2.5% processing fee (min $1.50).

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39. 1. Receive an email copy of this form.
40. Email address

    This field is not part of the form submission.

41. Submit Submit and Print

* indicates a required field