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2. GENERAL INFORMATION
4. Your First Name*
5. Your Last Name*
7. Your Email
8. Your Phone Number*
10. Your Organization (if relevant)
12. Your Address*
14. Address2
16. City*
17. State*
18. Zip*
20. Which of the following applies to you?*

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

    If you selected General Public or Government Official, write "none."

22. I am requesting this information:*

    1. On my own behalf
    2. As an authorized agent of another individual
24. AUTHORIZED AGENT INFORMATION
26. If you are an authorized agent requesting this information on behalf of another individual, please include the other individual's name, address, and phone number below.*

    If you are requesting this information on your own behalf, write "not applicable."

28. Proof of authorization, if applicable

    If you are an authorized agent, please upload proof that you are authorized to act on behalf of the other individual, or use the box to the left/below to explain. You can skip this step if you are requesting the information on your own behalf. 

29. Additional proof of authorization, if applicable:
31. VOTER INFORMATION REQUESTED
33. Voters to Include*

    1. Active
    2. Active & Inactive
34. Include vote history?*

    1. Yes
    2. No
35. Parties to Include*

    1. Any
    2. Specific Party
37. If you selected Specific Party above, please list the party (or parties) you would like included.
39. What voter district information should be included?*

    1. Countywide - Grand County
    2. Citywide - Moab
    3. Thompson Springs
    4. Castle Valley
    5. Option not listed / specific voting district

    Select all that apply.

40. If the voting district you want is not listed, or if you only require a specific voting district, please specify which districts here.
42. Please explain the purpose for which you are requesting this information.*
44. I understand that data for voters qualified as an At-Risk Voter will not be included in my voter file.*

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

    1. Yes
48. I understand that obtaining voter information under false pretenses, or providing or using the information in a manner that is prohibited by law, is punishable as a class A misdemeanor and by a civil fine.*

    1. Yes
50. I will ensure, using industry standards security measures, that the information received will not be shared with or accessed by unauthorized individuals or with anyone whom I believe will not use or share the information in a lawful manner.*

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

    1. Yes
54. I agree to only use the voter information for political purposes, another purpose expressly permitted specifically under USC Title 20A, Part 6, another purpose permitted by state or federal law, or as permitted by order of a court with jurisdiction.*

    1. I agree
56. FOR GOVERNMENT OFFICIALS: Do you agree to only use and share the information to the extent necessary to fulfill an official duty imposed by law. And further, do you agree to not provide or use the information obtained from the voter registration records in a manner that is prohibited by law?*

    1. I agree
    2. I am not a government official
58. FOR POLITICAL PARTIES AND AGENTS OF POLITICAL PARTIES: Do you agree to only use the voter information to communicate with an individual who is affiliated with the political party in relation to the business of the political party or for a political purpose; to verify that the voter is a member of the political party; to conduct demographic or other analysis for a political purpose; or for another purpose described in USC 20A-2-607(3)?*

    1. I agree
    2. I am not a political party or agent of a political party
60. 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
62. Electronic Signature:*
66. Fee Schedule (as of August 2024)

    Statewide	$1,050
    State Senate (Single County)	$100
    State Senate (Multi-County)	$25
    State House (Single County)	$50
    State House (Multi-county)	$25
    State School (Single County)	$100
    State School (Multi County)	$50
    1st Class County	$350
    2nd Class County	$150
    3rd Class County	$100
    4th Class County and below	$75
    1st Class City	$100
    2nd Class City	$75
    3rd Class City and below	$50
    Town	$15
    Local School Board	$25
    Single Precinct	$15
    Subscription Reports	$15

    
    

    Fees 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). ACH transactions will incur a $0.75 fee. 

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68. 1. Receive an email copy of this form.
69. Email address

    This field is not part of the form submission.

70. Submit Submit and Print

* indicates a required field