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Election Justice USA - Voting Issue Form - General Election Nov 2016
Election Justice USA is extremely concerned about the integrity of our elections. We aim to ensure the restoration of democracy and fight any voter suppression or election fraud.

This form is designed to easily and privately gather your confidential information regarding voting or registration issues to collectively analysis recurring issues and possibly support upcoming legal recourse to protect our right to vote.

After completing the form, if possible, please also send us copies of any evidence that you may have relating to your registration and subsequent events which you have described. (Copies of emails, screen shots, photos, documents scans, if any.) Send to: electionjusticeusa@gmail.com. Share this form widely and encourage everyone you know to follow the same steps.

Please note that ALL personal information provided will be kept 100% confidential. Election Justice USA will NEVER share your information without your express permission. You may be contacted by Election Justice USA to complete notarized affidavit that can be used for any potential court filings.

Full Name *
Your answer
Date of Birth (be sure to modify the year field) *
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State in which you registered to vote (e.g., "California"): *
Your answer
City/Town: *
Your answer
Home Address *
Your answer
Zip code: *
Your answer
Telephone Number(s) *
Your answer
E-mail Address *
Your answer
Which state county do you live in (e.g., "Orange County")? *
Your answer
I am here to report an issue with: *
If you selected the third option in the above question, please type "N/A" for subsequent required questions that do not apply to you (enter your DOB if it's a required date), and describe the nature of what you'd like to report immediately below. Provide as much relevant detail as possible and e-mail ALL evidence (scans, photos, links, forwarded e-mails) to ElectionJusticeUSA@gmail.com. Describe below:
Your answer
The deadline to change party affiliation for each state differs. The deadline for a brand new voter registration (for someone previously unregistered) may differ from the deadline to change party affiliation. PLEASE double-check the rules for your state, and only proceed with the rest of this form if you registered or changed affiliation before your state's deadline to do so. Below, please indicate the date that you last registered to vote or purposefully changed party affiliation (be sure to modify the year field as necessary - approximate date is OK if you don't know the exact date): *
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Date of the election *
Your answer
Polling Location; Polling Number (if available) *
Your answer
Specific issue you encountered *
Your answer
Verification: When I checked my registration on the above date, I discovered I was: *
If you found that you were not properly registered, or your party affiliation was missing or incorrect, please describe any efforts you made to correct the record, and the results of your effort. Provide as many specifics as possible, including dates, names, places, and positions of any contacts you made.
Your answer
We receive a number of media requests, one of which is to interview complainants (sometimes on the record, sometimes off the record). Would you be willing to speak to a reporter if we had such a request? We would only ever share your contact information, with your permission. *
By typing your full name below, you certify that all of the information provided above is true and correct to the best of your knowledge. Please note: one of our attorneys will be in touch with you soon to have this affidavit material notarized. *
Your answer
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