Election Justice USA - NY Voter Registration Problem Report Form
Initial findings suggest that a significant percentage of New York 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 to ensure that this issue is addressed BEFORE the New York presidential primary election on April 19th. 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 New York 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* New York 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: justice@ElectionJusticeUSA.org

• Please be sure to contact ALL and EVERY New York voter you possibly can. We must convince as many NY 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 an existing registration in New York was Oct. 9th, 2015. The deadline for a brand new voter registration (for someone previously unregistered) was Mar. 25th, 2016. Complete this form ONLY if you registered or changed party affiliation BEFORE the relevant deadline.

Please note that ALL personal information provided will be kept 100% confidential. Election Justice USA will NEVER share your information without your express permission.
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When I attempted to vote in the NY Presidential Primary: *
If you appeared before a judge in order to vote normally, how many hours did the entire voting process take? If you did NOT appear before a judge *and then vote normally*, skip this question.
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Full Name *
Date of Birth (be sure to modify the year field) *
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City/Town: *
Street Address *
Zip Code: *
Telephone Number(s) *
E-mail Address *
Which NY county do you live in? *
The deadline to change party affiliation for an existing registration in New York was Oct. 9th, 2015. The deadline for a brand new voter registration (for someone previously unregistered) was Mar. 25th, 2016. 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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On the date in the last question: *
Where did you register to vote (if registered online, please indicate ONLINE)? *
Party Affiliation (e.g. "I registered as a Democrat.”) *
Describe any confirmation you received of your registration, including any acknowledgement your party affiliation. PLEASE include any confirmation number(s) you received via e-mail. Also mention what type of evidence you can provide to support your claims (e-mails, scans/photos of paper documents, screenshots, etc. -- e-mail it to justice@ElectionJusticeUSA.org).
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) *
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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.
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. *
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