Date:
Voter's Last Name:
Voter's First Name:
Voter's Middle or Maiden Name:
Voter's Date of Birth (mm/dd/yyyy):
Voter's Guilford County Address (no P.O. boxes):
City:
Zip Code:
Requester:	SelfRelative (Fill fields below)
Requester's Name:
Requester's Address:
Relationship to Voter:	Brother Child Daughter-in-Law Father-in-Law Grandchild Grandparent Mother-in-Law Parent Sister Son-in-Law Spouse Stepchild Stepparent Verifiable Legal Guardian