OF MATT SCHULTZ LUCAS Bumomo SECRETARY or STATE DES Momma, IowA 503 19 era ce OFFICE or THE IowA SECRETARY or STATE Notice of Potential Ineligibility Citizen) to Registrant Form 2 (Date) (Voter' name and address) RE: Important Notice Regarding [Iowa Voter Registration Number] - Dear Mr. Ms. - We wrote you a letter on [date] saying that we have received information indicating you may not be a U.S. citizen and records show you are currently registered to vote in [countyname] County. the best of our knowledge, you have not responded to our initial letter.] or [The proof of citizenship dociunentation you provided in response to our initial letter is not sufficient and additional credible documentation is still required.] or [You requested more time and number of days have passed without our receipt of any further information from you.] In Iowa, only U.S. citizens can register and vote. See Iowa Code section 48A.5 (2) (2011). The immigration information we are relying on is information you previously gave to the Iowa Department of Transportation when you first applied for or renewed your driver's license or state identification card. This immigration information was later cross-checked with the Department of Homeland Security (DHS) which was unable to confirm your status as a U.S. citizen. We are providing you with another opportunity to confirm or deny your status as a U.S. citizen at this time. Within fourteen (14) days after receiving this notice, please complete and return to the Secretary of State's office the enclosed '"Admissi0n orDeniul of Citizen Status" Return Form 2" (Attachment You may mail, fax, e-mail or bring the Return Form in person to the office. To the extent requested on the Return Form, please include a copy of any document that either shows that you are not the person identified in this notice, that you are a U.S. citizen or that your immigration status has otherwise changed. If your name is now different or has changed from the name that appears in the documentation you are now providing or previously gave to the Iowa Department of Transportation, be sure also to provide documentation of that name change. Examples of proof of U.S. Citizenship include but are not limited to: LLS. Birth Certificate. If you cannot find your birth certificate, please contact the vital statistics office in the state or U.S. territory that originally issued your certificate. U.S. Passport (booklet or card). If you cannot find your U.S. Passport, please contact the U.S. Department of State at 1-877-487-2778 (TTY 1-888-874-7793) or visit the website at: http: travel.state. gov passportf lost/ Consular Cert$cute of Birth. If you cannot find your U.S. Consular Certificate of Birth, please contact the U.S. Department of State 202-955-0521 or visit the U.S. Department of State's website at: http: travel.state. gov passport/ Phone 515-281-0145 Fax 515-28 1 -4682 sos.iowa.gov so os.iowa.gov Naturalization Certificate or Certificate of Citizenship. If you cannot find your Naturalization Certificate or Certificate of Citizenship, or believe that there is some problem with your records that needs to be corrected by the United States Citizenship and Inunigration Services (USCIS), please refer to the enclosed "Information for Registrants: Verification of Citizenship Status and How to Obtain Your Document or Correct Your Record with (Attachment If you believe that the information-received by this office is incorrect, please complete and return the Return Form as instructed above. We have also provided you with information about how to obtain and correct your DHS immigration records. If you do not respond to this notice within 14 days or you provide documentation proving the information received by this office is correct, your voter registration record may be challenged. If this occurs, there will be a hearing with your county auditor before your name is removed from the voter registration rolls. If a challenge to your voter registration is filed within 70 days of an upcoming election, the hearing will not be scheduled until after the upcoming election. Please note that voter registration fraud is a class felony in the state of Iowa. You may take steps to remove your name from the voting rolls by sending a written notice requesting removal from the voter registration list. This request may be indicated on the Return Form included with this letter or may be mailed directly to the [countyname] County Auditor at [address]. For any questions or assistance, you may contact our office as follows: By Phone: By Mail: Iowa Secretary of State Attn: Voter Registration 321 E. St. Des Moines, IA 50319 By Email: sos@sos.iowa.gov By Fax: 515-281-4682 Sincerely, Matt Schultz Iowa Secretary of State Enclosures: Iowa Department of Transportation Record Screen Shot Voter Registration Record Screen Shot Admission or Denial of Citizen Form 2 with Self-addressed Return Envelope U.S. Department of Homeland Security' "How to Obtain Your Document or Correct Your Records with Phone 5 1 5-28 1 -0 145 Fax 515-281--4682 s0s.iowa. gov sos@sos.iowa.gov -- Arrscaivrsura I STATE OF IOWA P4 nv oi ADMISSION on DENIAI. OF NON-U.S. CITIZEN STATUS RETURN Fo1z1vI 2 Please complete and return this form no later than fourteen (14) days after receiving this notice of potential ineligibility from the Secretary of State. lf you do not respond within fourteen (I4) days your voter registration may be challenged, which could lead to the removal of your name from the voting rolls. lf your voter registration is challenged within 70 days of an upcoming election, the challenge hearing will be hold after the upcoming election. Under penalties of perjLu?y, I swear or affirm that (check applicable statements): I am the same person referred to in the letter I received from the state and I am not a U.S. citizen. El I am the same person referred to in the letter I received from the state but I am a U.S. citizen. I am enclosing a copy of proof of U.S. citizenship. I need more time to provide proof of U.S. citizenship because I am currently seeking a records review or correction, or replacement copy of the documentation or record in support of my U.S. citizenship from . I am not the person referred to in the letter I received from you. I have written my correct information in the spaces provided below. Last Name First Name Middle Name Date of Birth Iowa Driver's License or State ID Last four digits of Social Security House Number and Street City State Zip Code I Phone and! or email address SIGNATURE: DATE: RETURN FORM TO: Iowa Secretary of State Matt Schultz Attention: Voter Registration 321 E. sr. Des Moines, IA 50319 Phone: Email: sos@sos.iowa.gov Please note.? lowo driver 's license number/Iowa identification card number and social security number are exempt jrom public disclosure on voter registration lists under lowa Code section 48.4.8.