HomeMy WebLinkAboutVOTER REGISTRATION CANCELLATION FORM
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: