CALIFORNIA VOTER REGISTRATION RECEIPT

RECEIVED
AFFIDAVIT NUMBER
02/10/2022
65CN263657

Print, Sign and Mail

• Print and sign your application. You must fold and tape the form for mailing. Put the
county elections office address on the outside. Place a first-class stamp in the box in the
upper-right corner.

Important Notices
• This page is your receipt. Keep it until you get a Voter Notification Card in your mail.
If you have any questions, please contact your county elections office and give the
affidavit number above.
• The law protects your voter registration information against commercial use. Report any
problems to the Secretary of State’s Voter Hotline at (800) 345-VOTE (8683) or email
elections@sos.ca.gov.

MICHAEL VU
SAN DIEGO REGISTRAR OF VOTERS
5600 OVERLAND AVE SUITE 100
SAN DIEGO, CA 92123-1278

858-565-5800
rovmail@sdcounty.ca.gov
 CALIFORNIA VOTER REGISTRATION APPLICATION
SAN DIEGO COUNTY
5600 OVERLAND AVE SUITE 100
65CN263657
SAN DIEGO, CA 92123-1278
858-565-5800

*65CN263657*
NAME & ADDRESS CALIFORNIA ID SSN4 DATE OF BIRTH
Mr. Polley, Matthew Sr. A0870162 8683 10/24/1975
1259 WASHINGTON PL
STE 2665
EL CAJON, CA 92019
PHONE NUMBER PLACE OF BIRTH
858-428-7066 NEW YORK

EMAIL
mp.mapping@gmail.com
MAILING ADDRESS LANGUAGE
ENGLISH
PERMANENT VOTE-BY-MAIL VOTER
No
RECEIVE VOTER INFORMATION GUIDE BY MAIL BEFORE
EACH STATEWIDE ELECTION
No
IF NO ADDRESS, DESCRIPTION
RECEIVE SAMPLE BALLOT GUIDE BY MAIL BEFORE EACH
STATEWIDE ELECTION
No

ELECTRONIC NOTIFICATION EMAIL

Mpmapping@gmail.com
PRIOR REGISTRATION (IF APPLICABLE)
VOLUNTEER

DID SOMEONE HELP YOU FILL OUT THIS FORM? POLITICAL PARTY
NO PARTY PREFERENCE
YES NO
ETHNICITY/RACE
WHITE, NOT OF HISPANIC ORIGIN

I am a U.S. citizen.

I will be at least 18 years old by the next election.

READ, SIGN AND DATE BELOW

I declare under penalty of perjury under the laws of the State of California that:
• I am a U.S. citizen and will be at least 18 years old on election day.
• I am not currently serving a state or federal prison term for the conviction of a felony.
• I have not currently been found to be mentally incompetent by a court of law.
• I understand that it is a crime to intentionally provide incorrect information on this form.
• The information on this form is true and correct.

MAIL IMMEDIATELY 02/10/2022

SIGNATURE DATE (MM/DD/YYYY)

 FOR OFFICIAL USE ONLY

FIRST CLASS
STAMP
NECESSARY
FOR
MAILING

MICHAEL VU
SAN DIEGO REGISTRAR OF VOTERS
5600 OVERLAND AVE SUITE 100
SAN DIEGO, CA 92123-1278

TAPE HERE TAPE HERE