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Election Justice USA - Voter Problem Report Form - 2016 Primary Election
Initial findings suggest that a significant percentage of American voters are experiencing problems with voter registration leading up to the 2016 presidential primaries. Most commonly, this has involved unauthorized changes to registered party affiliation, though there have been a number of other relevant complaints. Regardless of whether these problems are the result of technical or clerical error, Election Justice USA will soon be filing a lawsuit in each affected state to ensure that this issue is addressed BEFORE relevant upcoming primary contests. If your voter registration information has been affected in any way, please fill out the following form.

The reason this form (securely, through Google Forms) requests personal information is that Election Justice USA attorneys will be restructuring the data in a way that is affidavit-ready and class action-ready. You will be contacted by one of our attorneys to ask if you wish to allow us to use your story in our legal case and, if so, to notarize an affidavit prepared from the information you provide below. You will NEVER be asked for money. Please note that ALL personal information provided will be kept 100% confidential. Election Justice USA will NEVER share your information without your express permission.

If you have not yet checked your registration status, please visit http://www.canivote.org before filling out this form. Only fill out this form if there is a problem with *your* voter registration.

• After completing the form, if possible, please also send us copies of any documentation 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

• Please be sure to contact ALL and EVERY voter you possibly can. We must convince as many voters as possible to 1) check their registration status, and 2) fill out this form (by visting www.ElectionJusticeUSA.org) if anything is amiss.

• 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. Your chosen candidate's website will likely have this information readily available for your state.

Please note that ALL personal information provided will be kept 100% confidential. Election Justice USA will NEVER share your information without your express permission.

Full Name
Your answer
Date of Birth (be sure to modify the year field)
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DD
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YYYY
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):
MM
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DD
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YYYY
On the date in the last question:
Where did you register to vote (if registered online, please indicate ONLINE)?
Your answer
Party Affiliation (e.g., "I registered as a Democrat.”)
Your answer
Describe any confirmation you received of your registration, including any acknowledgement your party affiliation.
Your answer
Verification: I checked my registration online OR at the polls on ______ (date; provide approximate date if exact date is uncertain - be sure to modify year field if needed)
MM
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DD
/
YYYY
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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