SPECIAL INSTRUCTIONS: Return IMMEDIATELY

COMPLIANCE with this State requirement provides proof of residence to protect voting rights, veteran’s bonus, housing for the elderly and related benefits as well as providing information for selection of jurors. This form DOES NOT register you as a voter.

GENERAL INSTRUCTIONS 1. List ALL family or household members whose legal address is the same. Include any member of the family in Military Service, away at school or confined to a rest home whose legal residence is the same. 2. MOVE/DECEASED – Enter “M” of “D” if appropriate. 3. MAIL TO – Designates the person in your household to whom mail should be addressed. If you wish to change enter an “X” next to that individuals name. 4. OCCUPATION:

Enter occupation, not place of employment.

5. NATIONALITY:

Enter only if not a U.S. citizen.

6. VETERAN:

Check if you are a U.S. Veteran.

7. To return this form:

Mail to:

Thank you for your cooperation.

Town Clerk’s Office North Andover Town Hall 120 Main Street North Andover, MA 01845

IMPORTANT LEGAL DOCUMENT ANNUAL STREET LISTING IMPORTANT: State Law requires that you be sent an annual street listing. Please update the information below. Please sign and respond within ten (10) days, even if no changes are necessary. For assistance call the Town Clerk's Office at 978-688-9501 Current address: WARNING: Failure to respond to this mailing shall result in removal from the active voting list and may result in removal from the voter registration rolls. INSTRUCTIONS: Please print. Update the information provided by adding, deleting, or making changes below the printed information. Designate the head of your household by marking an "X" in the second column next to the name. The ninth column labelled Moved/Deceased asks if the person(s) listed has moved or is deceased. Enter 'M' or 'D' if appropriate.

Telephone Number * Signature of Respondent

Date

Signed under the Penalties of Perjury as prescribed by M.G.L. CH 56, S4.

g1 g2 g3 g4 g5 g6 g7 g8 g9 g10 g11 g12 g13 g14 g15 g16

h1 h2 h3 h4 h5 h6 h7 h8 h9 h10 h11 h12 h13 h14 h15 h16

j1 j2 j3 j4 j5 j6 j7 j8 j9 j10 j11 j12 j13 j14 j15 j16

t1 t2 t3 t4 t5 t6 t7 t8 t9 t10 t11 t12 t13 t14 t15 t16

l1 l2 l3 l4 l5 l6 l7 l8 l9 l10 l11 l12 l13 l14 l15 l16

m1 n1 m2 n2 m3 n3 m4 n4 m5 n5 m6 n6 m7 n7 m8 n8 m9 n9 m10n10 m11n11 m12n12 m13n13 m14n14 m15n15 m16n16

# of Cats

i1 i2 i3 i4 i5 i6 i7 i8 i9 i10 i11 i12 i13 i14 i15 i16

# of Dogs

f1 f2 f3 f4 f5 f6 f7 f8 f9 f10 f11 f12 f13 f14 f15 f16

US Veteran Y/N

d1 e1 d2 e2 d3 e3 d4 e4 d5 e5 d6 e6 d7 e7 d8 e8 d9 e9 d10 e10 d11 e11 d12 e12 d13 e13 d14 e14 d15 e15 d16 e16

Moved/Deceased

mm/dd/yyyy

If non-U.S. citizen

Middle c1 c2 c3 c4 c5 c6 c7 c8 c9 c10 c11 c12 c13 c14 c15 c16

Occupation Nationality

First b1 b2 b3 b4 b5 b6 b7 b8 b9 b10 b11 b12 b13 b14 b15 b16

Date of Birth

Party*

Last, a1 a2 a3 a4 a5 a6 a7 a8 a9 a10 a11 a12 a13 a14 a15 a16

Previous Address

Mail to*

Name

Sex* M/F

The following fields are optional and are denoted as such by an asterisk '*': mailto, sex, Party, number of cats and telephone number.

Unlisted