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Address Confirmation Notice Reply Form

If you have received an address confirmation request or address confirmation final notice from our office, your name is correct on the notice and you are continuing to live in Brevard County, you can use the form below to reply to the notice and maintain your active registration status. If you are making a name change or if you are residing in Florida but not in Brevard County, you will need to use the Florida Voter Registration Form to submit your name and/or address change. If you are no longer living in Florida and wish to have your Florida voter registration cancelled, please sign the and return the confirmation notice. If you have any questions about this form, please e-mail us at lwhite@brevardelections.org.

Name:

Date of birth:

Voter registration number (if known):

Phone number:

E-mail address (required):

Brevard County residence address:



Check if you do not have a permanent residence address in Brevard County and are living outside of the county but intend to remain a permanent resident of the county. (If this applies to you, do not enter an address in the space above)

Old Brevard County residence address (if you have changed your address since the last time you voted or contacted our office):



Mailing address (if different from residence address):



Old mailing address (if your mailing address has changed):



Additional comments:


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