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The form by which a person may decline to register to vote that is required by § 2-2-204(a)(2) shall include the following:
The question: “If you are not registered to vote where you live now, would you like to apply to register to vote here today?”;
If the 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.”;
Boxes for the applicant to check to indicate whether the applicant would like to register or declines to register to vote, together with the statement “IF YOU DO NOT CHECK EITHER BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER TO VOTE AT THIS TIME.”;
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.”; and
The statement, “If you believe that someone has interfered with your right to register or to decline to register to vote or your right to privacy in deciding whether to register or in applying to register to vote, you may file a complaint with the coordinator of elections.” The statement shall also include the address and telephone number of the coordinator of elections.
Each voter registration agency shall maintain the declinations completed by their clientele.