VOTER REGISTRATION CANCELLATION FORM

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07/2021 COUNTY OF HAWAI'I Affidavit for Cancellation of Voter Record IMPORTANT: PRINT CLEARLY IN BLACK INK. FAILURE TO COMPLETE ALL ITEMS WILL PREVENT ACCEPTANCE OF THIS AFFIDAVIT. Instructions: To cancel YOUR voter registration complete only PART 1 (Voter Initiated Cancellation) PART 1. Voter Initiated Cancellation Name: Date of Birth: Residence Address: By signing below, I hereby affirm that the information above is true and correct, and authorize the City/County Clerk to cancel my voter registration in the State of Hawai'i. Signature: Date: A witness must sign below if a voter uses a mark as a signature. Witness Signature _________________________________________ Address/Phone: _________________________________________ To cancel the registration of a DECEASED individual, complete only PART 2 (Deceased Voter Cancellation) PART 2. Deceased Voter Cancellation Decedent’s Name: Date of Birth: Residence Address: Requestor’s Name: Address: Relationship to Decedent: Contact Phone No: By signing below, I hereby affirm that the information above is true and correct, and authorize the City/County Clerk to cancel my voter registration in the State of Hawai'i. Signature: Date: Office Use Only Date Processed: Initials: Status: