Louisiana Administrative Code
Title 31 - ELECTIONS
Part II - Voter Registration
Chapter 4 - Voter Registration at Mandatory Voter Registration Agencies in the State that Provide Public Assistance or Provide State-funded Programs Primarily Engaged in Providing Services to Persons with Disabilities
Section II-407 - Declaration Form

1. the question:

"If you are not registered to vote where you live now, would you like to apply to register to vote here today?";

2. boxes for the applicant to check to indicate whether the applicant would like to register to vote or declines to register to vote (failure to check either box being deemed to constitute a declination to register to vote for purposes of providing assistance in completion of the registration application form), together with the statement (in close proximity to the boxes and in prominent type):

"IF YOU DO NOT CHECK EITHER BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER TO VOTE AT THIS TIME."

3. if the mandatory voter registration agency provides public assistance, the statement:

"Applying to register or declining to register to vote will not affect the amount of assistance that you will be provided by this agency."

4. the statement:

"If you would like help in filling out the voter registration application form, we will help you. The decision whether to seek or accept help is yours. You may fill out the application form in private."

5. the statement:

"For assistance in completing the voter registration application form outside our office, contact ___________ at ____________."

6. the statement:

"If completed outside our office, this declaration form and your completed voter registration application form (if you filled one out) should be returned to __________ or ____________."

7. the statement:

"If you believe that someone has interfered with your right to register or to decline to register to vote, your right to privacy in deciding whether to register or in applying to register to vote, or your right to choose your own political party or other political preference, you may file a complaint with the Louisiana Secretary of State, Commissioner of Elections, P.O. Box 94125, Baton Rouge, LA 70804-9125, Telephone (toll-free) 1-800-883-2805."