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NCSTATEBOARDOFELECTIONS

NOTIFICATIONOFDECEASEDVOTER P.O.BOX27255
RALEIGH,NC276117255
NorthCarolina
PHONE:18665224723 FAX:9197150135
elections.sboe@ncsbe.gov


PURPOSE
ThisformisintendedtoprovidenotificationofthedeathofaNorthCarolinaregisteredvotertoacountyboardofelections.Upon
confirmationofthevoter,thecountyboardofelectionswillremovethevoterfromthecountyslistofregisteredvoters.Thisformmay
onlybecompletedbyanearrelativeorpersonalrepresentativeofthedeceasedvotersestate.

INSTRUCTIONS
Completethisformasthoroughlyaspossible.Requestedinformationwillbeusedtoensurethatwehavethecorrectvoter.Signtheform
andthensubmit(mail,fax,orscan&email)ittothecountyboardofelectionsofficeinthecountyinwhichthedeceasedvoterlivedprior
todeath.Contactinformationforthecountyboardsofelectionsisavailableat:www.ncsbe.gov.

DeceasedVoterInformation
LastName FirstName MiddleName Suffix


DateofBirth(MM/DD/YYYY) Age Gender Last4DigitsofSSN DriverLicenseorIDNo. VoterRegistrationNumber(ifknown)

Male
Female
VoterRegistrationAddress LastKnownAddress(Ifdifferentthanvoterregistrationaddress)

City State County City State County


CountyofRegistration DateofDeath(ifknown) CountyofDeath(ifknown) StateofDeath(ifknown)

PersonProvidingDeceasedVoterInformation
FullName Relationshiptovoter:(Required,pleasecheckone)
NorthCarolinalawdefinesaNearRelativeas:
spouse sibling parent stepparent
Address
child stepchild grandchild grandparent

mother/father/daughter/orsoninlaw
City State ZipCode Legalguardian
Representativeofestate
Signature

X
Signature(Required) DateSigned

Thankyouforprovidingthisinformation.
SendFormTo:


AdministrativeUseOnly
NCSTATEBOARDOFELECTIONS
P.O.BOX27255 AttachRegistrationListLabelHere
RALEIGH,NC276117255 (Ifapplicable)


V2013.11