State of Illinois Date of Notice: October 01, 2024

Department of Human Services Case Number: 408872704

Department of Healthcare and Family Services Client Name: LAURA L ORR
Individual ID: 1006044069
Office Name: VERMILION COUNTY FCRC
Office Address: 220 S BOWMAN AVE
DANVILLE, IL 61832
FFDTDFFFAFDFAADDDTTDFTDAADDFDTTFATAFFTDTTDDTADTDDATDFFATFFTTAADFT Phone: 217-442-4003
TTY:
Fax: 844-736-3563
LAURA L ORR
1831 PERRYSVILLE RD You can manage your case online at abe.illinois.gov
LOT 62 Esta notificación está disponible en Español. Usted
DANVILLE, IL 61834 puede solicitarla por Internet en abe.illinois.gov o
llame al 1-800-843-6154 (TTY 1-866-324-5553)

Medical Benefits: Time to Renew Notice

Dear LAURA L ORR ,

It is time to renew medical benefits!

Based on the information we have today, the members of your household listed in the table
below must complete the included redetermination form by November 01, 2024 to continue
receiving medical benefits after November 2024.

To learn how to renew medical benefits, read the first page of the SNAP Redetermination Form
Interview Required and Medical Benefits Renewal Form which is included in this envelope.

Turn this page over to read more information on the back.

HFS 2381C (N-04-24) Medical Redetermination Page 1 of 2

Notice
96221153
 Name Birth Date Medical Medical Action
ID(RIN) Group Required
LAURA L ORR 03/02/1972 075811810 FamilyCare Yes

"Action Required= Yes" Individual must complete and return form included.
"Action Required= No" Individual's medical benefits have been automatically renewed.

Call us at the phone number listed at the top of this form if you cannot send everything on time
or if you have questions. We may be able to help you get the information you need.

Financial Review for Eligibility

We checked our electronic sources to decide if we could automatically renew your medical
benefits. Because we could not make a decision using only electronic sources for all household
members, a redetermination form must be completed for members requiring further action.

The tables below show the income information we have about your case.

The following table shows the most recent income information in our records.

Individual Name Employer/Income

Frequency
LAURA L ORR Other Self Employment/

HFS 2381C (N-04-24) Medical Redetermination Page 2 of 2

Notice
96221153
 State of Illinois Date of Notice: October 01, 2024
Department of Human Services Case Number: 408872704
Department of Healthcare and Family Services Office Name: VERMILION COUNTY FCRC
Office Address: 220 S BOWMAN AVE
DANVILLE, IL 61832
Phone: 217-442-4003
Fax: 844-736-3563

FFDTDFFFAFDFAADDDTTDFTDAADDFDTTFATAFFTDTTDDTADTDDATDFFATFFTTAADFT
You can manage your case online at abe.illinois.gov

LAURA L ORR Esta notificación está disponible en Español. Usted

puede solicitarla por Internet en abe.illinois.gov o
1831 PERRYSVILLE RD llame al 1-800-843-6154 (TTY 1-866-324-5553)
LOT 62
DANVILLE, IL 61834

SNAP Redetermination Form

Interview Required
and Medical Benefits Renewal Form

Attention: Action Required

Your Medical and SNAP benefit period is ending November 30, 2024. If you do not complete a
redetermination your benefits will stop. To keep getting benefits without a break and to allow time for us to
process your redetermination, please complete it by November 01, 2024, but, no later than November 15,
2024.

Use one of the 4 easy ways below:

1. Complete the electronic version of this form online in ABE Manage My Case at abe.Illinois.gov; or
2. Complete your SNAP and Medical redetermination over the phone by calling
1-800-843-6154/1-866-324-5553 TTY; or
3. Fill out, sign, and send us this form and all verifications we ask for. You may send the form by mail or
fax.
l Mail to P.O. Box 19138, Springfield, IL 62763; or
l Fax the form to 1-844-736-3563; or
4. Complete your redetermination in person. Bring this form and your verifications to the office listed
above.
You must have an interview with a caseworker to reapply for SNAP. An interview is not needed for
medical benefits. Check one of the boxes below if you are returning this form to the Family Community
Resource Center.Check one of the boxes below so we can schedule your interview.
I am elderly, ill, disabled, employed, or have some other hardship and need to be interviewed by
phone. Enter phone number in question #8 below.
x I am able to come to the office for an interview.
We will schedule your interview when your application is returned to us. If you do not keep a scheduled
interview, it is up to you to ask for another one.

VRS[96221153]
Turn this page over to read more information on the back.
IL444-1893 (R-07-23) SNAP Redetermination Page 1 of 7
Form Interview Required and Medical Benefits
Renewal Form 96221153
 1. Do these people still live with you?
LAURA L ORR 03/02/1972 x Yes No
HALLE WIECK 08/28/2007 x Yes No

2. Are there other people living with you not listed above? If yes, list them here.
Full Name Birth Date Relationship Eats with you?
Yes No
Yes No
Yes No
Yes No
For additional persons, please attach a separate sheet.

3. Does anyone get paid for working? o x Yes o No If YES, enter their name below. Attach
copies of the last 4 pay stubs if paid weekly, last 2 pay stubs if paid every other week
or twice a month, and the last pay stub if paid monthly. If self-employed, attach your
income and expense statement for the last 30 days. If someone got tips that are not on
Laura Orr
their pay stubs, tell us Who? ______________________ and the total amount of tips
400.00
received in the last 30 days. Total tips $ __________
List the Name of Name of Employer Rate of Pay Hours How often is the person
Everybody Who If a person works Worked paid? Weekly, every 2
is Working more than one job, Weekly weeks, twice a month,
list all the employers. monthly, other?
Laura Orr Frank Strohkirch 400.00 monthly
10-15

Attach a sheet of paper if you need more room to list your family's income.

x No If YES, complete the information above.

4. Did you or anyone start a new job? o Yes o

x No If YES, enter name, reason

5. Did anyone stop working or did their job end? o Yes o
and final pay date. _________________________________________________________
________________________________________________________________________

6. During the last 30 days did anyone receive any other income such as Child Support, Social
Security, SSI, Unemployment, VA, Worker's Compensation, Contributions or any other
money? o Yes o x No If YES, complete the box below.

Name Type of Income Amount How Often

$
$
Attach a sheet of paper if you need more room to list your family's income.

VRS[96221153]
IL444-1893 (R-07-23) SNAP Redetermination Page 2 of 7
Form Interview Required and Medical Benefits
Renewal Form 96221153
 Note: If everyone in your SNAP case receives or plans to apply for SSI, you may reapply for
SNAP at your local Social Security Administration (SSA) office. You must do this by
November 15, 2024. The SSA office will forward your application to us to process.

x No If YES,
7. Do you expect any changes in anyone's income or employment? o Yes o
what is the change? ________________________________________________________
When do you expect this change to happen? ____________________________________

x Yes o No If No, tell

8. Is the address at the top of this page your correct mailing address? o
us the correct mailing address:
________________________________________________________________________
Our records show that you live at 1831 PERRYSVILLE RD, LOT 62, DANVILLE, IL, 61834.
Is this correct? xo Yes o No If No, tell us the correct address where you live:
________________________________________________________________________
Our records show that these are your phone numbers. If not, tell us your correct numbers.
Phone Current Phone Number New Phone Number Receive Text Alerts
Type and Reminders*
(please check one)

Home 217-601-1376 x
o
Work
Cell 217-977-5147 o
Alternate o
*Standard fees may apply from your mobile service provider.

o I do not wish to receive text alerts and reminders.

9. How much is your rent: $ ______ Lot rent: $ 250.00

______ Mortgage $ ______ Enter any taxes
and homeowner's insurance paid separately: $ ______ Are any of these paid by someone
else? o Yes o No If YES, tell us who and how much: ____________________________

10. Did you receive an energy assistance payment of $21 or more this month or in the last 12
months from the Low Income Home Energy Assistance Program (LIHEAP), (in Chicago
paid through CEDA)? o Yes o x No Answering YES will not reduce your benefits. If NO,
do you pay for or are you billed separately from your rent or mortgage for heat or air
conditioning, or excess cost for heat or air conditioning? ox Yes o No Note: Air
conditioning is a window air or central air conditioning unit. If NO, do you pay any other
x Yes o No If YES, what utilities? ____________________________________
utilities? o
i pay water, and power
_______________________________________________________________________

x No If YES, who makes the

11. Does anyone in your household pay child support? o Yes o
payments, how much and how often? _________________________________________

VRS[96221153] Turn this page over to read more information on the back.
IL444-1893 (R-07-23) SNAP Redetermination Page 3 of 7
Form Interview Required and Medical Benefits
Renewal Form 96221153
 12. Does anyone in your household pay for the care of a child or disabled adult living in your
home so someone can work, attend training, or school, to prepare for a job? o Yes o x No
If YES, who is the care for, who provides the care, how much do you pay for the care and
how often? ______________________________________________________________

13. Does anyone who is age 18 or over attend school, other than high school, half-time or
more? o Yes ox No If YES, who? __________________________________________

14. Does someone in your unit who is 60 or older or is blind or disabled have monthly medical
expenses of $36 or more that are paid by you and not reimbursed or paid by someone
else? o Yes ox No

For your medical benefits, please answer the following questions.

x No
15. Are you or is anyone who lives with you pregnant? o Yes o

If yes, name: ____________________ Due date: _____ Expected number of babies: _____
End date: _______________

x No
16. Do you or anyone living with you have health insurance? o Yes o

If yes, name of insurance plan: ______________________ Policy Number ______________

Who is covered by this health insurance?
Name of insurance plan: ___________________________ Policy Number ______________
Who is covered by this health insurance?

17. Are you or anyone living with you interested in the partial-benefit program for Family
Planning if no longer eligible for Medical Benefits? o Yes o x No

If yes, name of the person(s) who want to Opt-In

18. Will you or anyone who lives with you file a federal income tax return next year to report
income received this year? o x Yes o No

Laura Orr
If yes, name of person(s) filing tax return: ________________________ Birth Date03/02/1972
_______
If this person will file jointly with a spouse, write name of spouse: ____________________
If this person will claim dependents on the tax return, write name(s) of dependents:
Halle Wieck
_____________________ 08/28/07
Birth Date _______ _____________________ Birth Date _______

VRS[96221153]
IL444-1893 (R-07-23) SNAP Redetermination Page 4 of 7
Form Interview Required and Medical Benefits
Renewal Form 96221153
 _____________________ Birth Date _______ _____________________ Birth Date _______

19. Will you or anyone who lives with you be claimed as a dependent on anyone's tax return for
this year o Yes ox No
If yes, name of dependent __________________________________ Birth Date __________
Tax filer's name and relationship to dependent: _____________________________________

For additional persons, please attach a separate sheet.

20. Do you or anyone living with you pay any expense that can be deducted on your federal
income tax return? o Yes o x No
If yes, list the expense: __________________________________ How Much? ___________
How Often? ______________________________________

Please answer the following two questions and return with your application. Your responses
to these questions are voluntary and will not affect your eligibility for benefits.

Are you Hispanic or Latino? Yes x No

What is your race? American Indian or Alaska Native

(Check all that apply) Asian
Black or African American
Native Hawaiian or Other Pacific Islander
x White

VRS[96221153] Turn this page over to read more information on the back.
IL444-1893 (R-07-23) SNAP Redetermination Page 5 of 7
Form Interview Required and Medical Benefits
Renewal Form 96221153
 Have you or someone in your household received any money from Lottery or Gambling Winnings of
more than $4,250.00? o Yes o
x No

If yes, please provide the information in the table below. Also include verifications for each game
winnings. If the winnings from a game were split with another member in your household, please
indicate how much each person received.

Name of Date Gross Gross Net Winnings Is the Name of Gross

Person Winnings Winnings Amount payment Person who Amount for
Amount Amount (after taxes one-time or split game the person
Received (before taxes or any ongoing? winnings who split
or any deductions) game
deductions) winnings

VRS[96221153]
IL444-1893 (R-07-23) SNAP Redetermination Page 6 of 7
Form Interview Required and Medical Benefits
Renewal Form 96221153
 CERTIFICATION AND CONSENT TO RELEASE GENERAL INFORMATION

Signature This application must be signed below.

By signing below; I swear or affirm, under penalty of perjury, the answers on this application are
true and correct to the best of my knowledge.

Signature laura l. orr Date 12/09/24

USDA Nondiscrimination Statement

In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights
regulations and policies, this institution is prohibited from discriminating on the basis of race, color,
national origin, sex (including gender identity and sexual orientation), religious creed, disability, age,
political beliefs, or reprisal or retaliation for prior civil rights activity.

Program information may be made available in languages other than English. Persons with disabilities
who require alternative means of communication to obtain program information (e.g., Braille, large print,
audiotape, American Sign Language), should contact the agency (state or local) where they applied for
benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through
the Federal Relay Service at (800) 877-8339.

To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA
Program Discrimination Complaint Form which can be obtained online at:
https://www.usda.gov/sites/default/files/documents/ad-3027.pdf, from any USDA office, by calling (833)
620-1071, or by writing a letter addressed to USDA. The letter must contain the complainant's name,
address, telephone number, and a written description of the alleged discriminatory action in sufficient
detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged
civil rights violation. The completed AD-3027 form or letter must be submitted to:

1. mail:
Food and Nutrition Service, USDA Do not send applications or any forms to this
1320 Braddock Place, Room 334 address.
Alexandria, VA 22314; or
2. fax:
(833) 256-1665 or (202) 690-7442; or
3. email:
FNSCIVILRIGHTSCOMPLAINTS@usda.gov

This institution is an equal opportunity provider.

VRS[96221153]
IL444-1893 (R-07-23) SNAP Redetermination Page 7 of 7
Form Interview Required and Medical Benefits
Renewal Form 96221153
 To contact IDHS, visit our website at:
State of Illinois
Department of Human Services www.dhs.state.il.us
or call the automated Helpline for
Information and Referral Services.
To find the address and phone number
of your local IDHS office, call:
1-800-843-6154 (Voice)
The Illinois Department of Human Services 1-866-324-5553 (TTY)
(IDHS) provides many services to help people in Representatives are available between:
Illinois have better lives, including information
8:00 a.m. - 5:00 p.m.
and referrals to services provided by other
agencies and community partners. Listed below Monday - Friday (except state holidays)
are services available to meet your individual For answers to your questions, please e-mail:
and family needs.
Medical Benefits
DHS.WebBits@Illinois.gov
SNAP Benefits or write:
Cash Assistance Illinois Department of Human Services
Employment and Training Services Bureau of Customer and Support Services
Alcohol and Substance Abuse Services
100 South Grand Avenue East, 2nd Floor
Domestic Violence Services
Mental Health Services Springfield, Illinois 62762
Services for Pregnant Women USDA Nondiscrimination Statement
Child Care Services In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil
Women, Infants and Children (WIC) rights regulations and policies, this institution is prohibited from discriminating on the basis
of race, color, national origin, sex (including gender identity and sexual orientation),
Services for Teen Parents religious creed, disability, age, political beliefs, or reprisal or retaliation for prior civil rights
Child Support activity.

Services for People with Disabilities Program information may be made available in languages other than English. Persons with
disabilities who require alternative means of communication to obtain program information
Group Care - Nursing Homes (e.g., Braille, large print, audiotape, American Sign Language), should contact the agency
Services for Senior Citizens (state or local) where they applied for benefits. Individuals who are deaf, hard of hearing or
have speech disabilities may contact USDA through the Federal Relay Service at (800)
LIHEAP 877-8339.
Earned Income Tax Credit (EITC) To file a program discrimination complaint, a Complainant should complete a Form
Crisis Nursery AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at:
https://www.usda.gov/sites/default/files/documents/ad-3027.pdf, from any USDA office, by
Food Pantries calling (833) 620-1071, or by writing a letter addressed to USDA. The letter must contain
Healthy Families Illinois the complainant's name, address, telephone number, and a written description of the
alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil
Homeless Services Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed
AD-3027 form or letter must be submitted to:

How Can I Apply for Services? 1. mail:

Food and Nutrition Service, USDA Do not send applications or any forms to
You can apply for services by going to 1320 Braddock Place, Room 334 this address.
your local IDHS office, or you can call the Alexandria, VA 22314; or
2. fax:
office and ask them to mail you an (833) 256-1665 or (202) 690-7442; or
application. In some cases, you can apply 3. email:
FNSCIVILRIGHTSCOMPLAINTS@usda.gov
for services over the phone or online. This institution is an equal opportunity provider.

DHS (R-11-15)
Guide To Services
Printed by authority of the State of Illinois
with funds from the TANF Program
35,000 copies P.O. #16-0525

VRS[96221153]

IL444-4474 (R-09-15) Guide to DHS Services Page 1 of 1

96221153
 Verifications

At this application you must report: childcare expenses, utility expenses, rent or mortgage
payment, property taxes and insurance. You must report and verify: Medical expenses, Child
Support paid.

If we need more information to process your application, we will give you a notice that tells you
what we need You must return the information within 10 calendar days. If you do not do this, your
benefits may be late or stop.

Failure to report or verify expenses will be seen as a statement by your household that you do
not want to receive a deduction for the unreported change.

Child Support payments are subject to verification by computer matching with the records of the
Division of Child Support Enforcement.

Voter’s Registration Information

If you want to register to vote, fill out the attached Illinois Voter Registration Application SBE (R-19) and
give it to your DHS office or your local election official. For help filling it out or for translation services,
contact your DHS Family Community Resource Center. You may also call the Helpline at
1-800-843-6154, or 1-866-324- 5553(for TTY). For information online, see www.dhs.state.il.us or
www.elections. il.gov/.

YOUR RIGHTS AND RESPONSIBILITIES Your Application Rights

You will receive a notice of decision on your SNAP and/or State Food eligibility. If you disagree with
the SNAP and/or State Food decision, you may ask for a fair hearing at any time within 90 days of the
date the local office notifies you of the decision. You will get the chance to explain your position to the
local office worker and later, to a hearing officer. You may bring another person to the hearing, such
as a friend, relative or a lawyer.

About Your Illinois LINK Benefits

If you have cash or SNAP and/or State Food benefits left in your Illinois Link account, you must use them
within 274 days (9 months) from the date they were first put in your account. If you do not use your
benefits within that time, you will lose them.

What will we do with the information you give to us?

DHS secures and uses information about all clients through the income and eligibility verification system.
This includes such information as receipt of Social Security Benefits, Unemployment Insurance, child
support payments, unearned income (such as interest and dividends), and wages from employment. We
will use any information we get to determine eligibility for benefits and the amount of benefits provided
for all programs. When information does not match, we may contact a third party, such as employers,
claims representatives or financial institutions to verify the information. The information we verify may
affect your eligibility for assistance and the amount of assistance provided. Information on this form
may be used in computer matching with other state and federal agencies, program review or audits,
and to make sure that the household is eligible or continues to remain eligible for SNAP and/ or State
Food benefits, other federal assistance programs, and federally assisted state programs, such as school
lunch, TANF and Medicaid.

Turn this page over to read more information on the back.

IL444-4765B (R-11-14) Verifications
Page 1 of 2
96221153
 The information on this form is subject to verification by Federal, State, and Local Officials. If
any information is found to be inaccurate, I may be denied SNAP and/or State Food benefits,
and/or be subject to criminal prosecution for knowingly providing false information.

What are the SNAP and/or State Food Program Penalties?

If you: Then you will lose SNAP and/or State Food benefits:
* Hide or give wrong information on purpose to * 12 months the first time
get SNAP and/or State Food benefits. * 24 months the second time
* Trade or sell SNAP and/or State Food benefits, * Permanently the third time
or resell food bought with SNAP and/or
State Food benefits.
* Use SNAP and/or State Food benefits to buy
non-food items like alcohol or tobacco.
* Use someone else's SNAP and/or State Food
benefits for yourself or someone else.
* Throw away beverages purchased with SNAP
and/or State Food benefits just to get money
back from a container deposit.

* Trade SNAP and/or State Food benefits * 24 months the first time
for controlled substances, such as drugs. * Permanently the second time

* Trade SNAP and/or State Food benefits * Permanently

for firearms, ammunition or explosives.
* Buy, sell or trade SNAP and/or State Food * Permanently
benefits of more than $500.
* Give false information about who you are and * 10 years
where you live so you can get extra SNAP
and/or State Food benefits.

You can also be fined up to $250,000 and put in prison up to 20 years or both. You can also be
charged under other Federal laws. Persons who are fleeing felons or probation/parole violators are
ineligible for SNAP and/or State Food benefits.

IL444-4765B (R-11-14) Verifications

Page 2 of 2
96221153
 ILLINOIS VOTER REGISTRATION APPLICATION
FOR ILLINOIS RESIDENTS ONLY TO COMPLETE THIS FORM: SBE R-19
TO VOTE YOU MUST: • Box 1-If you do not have a middle name, leave blank.
• Be a United States citizen • Box 3-If mailing address is same as Box 2, write "same".
Be at least 18 years old (some 17 year olds may vote in the • Box 4-By providing an email address you agree to receive
General Primary, Consolidated Primary or Caucus) election related notices via email.
• Live in your election precinct at least 30 days • Box 5-If you have never registered before, leave blank. If you
• Not be convicted and incarcerated. do not remember your former address; provide as much
• Not claim the right to vote anywhere else information as possible.
TO VOTE IN THE NEXT ELECTION: • Box 6-If you have not changed your name, leave blank.
• Mail or deliver this application to your County Clerk or • Box 10-If you have an Illinois Driver's License or Secretary of
Board of Election Commissioners no later than 28 days State ID, check the first box and fill in the number. If you do not
before the next election. Go to http://www.elections.il.gov have a Driver's License or SOS ID, check the second box and fill
in the last four digits of your Social Security Number. If you do not
IMPORTANT INFORMATION: have a SSN, check the third box and send a copy of the
• If you do not have a driver's license, State Identification Card or appropriate document (as described in the "Important Information"
social security number, and this form is submitted by mail, and section) along with this form.
you have never registered to vote in the jurisdiction you are now • Box 11-Read, date and personally sign your name or make
registering in, then you must send, with this application, either (i) your mark in the box.
a copy of a current and valid photo identification, or (ii) a copy of a IF YOU HAVE NO STREET ADDRESS,
current utility bill, bank statement, government check, paycheck, below describe your home: list the name of subdivision; cross streets;
roads; landmarks; mileage and/or neighbor's names.
or other government document that shows the name and address
of the voter. If you do not provide the information required above,
then you will be required to provide election officials with either (i)
N
or (ii) described above the first time you vote in person or prior to
voting by mail. W E
• If you change your name you must re-register.
• If you register at a public service agency, any information
regarding the agency that assisted you will remain confidential as S
will any decision not to register.
• If you do not receive a Notice within 2 weeks of mailing or If you have questions about completing this form, please call
delivering this application, call your County Clerk or Board of the State Board of Elections at (217)782-4141 or (312)814-6440
(or webmaster@elections.il.gov).
Election Commissioners.
TYPE OR PRINT CLEARLY IN BLACK OR BLUE INK
Are you a citizen of the United States of America? (check one) yes no Office Use
Will you be 18 years of age on or before the next election day OR are you currently 17 and
will be 18 by the day of the next General or Consolidated Election? (check one) yes no
If you checked "no" in response to either of these questions, then do not complete this form.
You can use this form to: (Check One) apply to register to vote in illinois change your address change your name
1. Last Name First Name Middle Name or Initial Suffix(Circle One)
Jr. Sr. II III IV

2. Address where you live (House No., Street Name, Apt. No.) City/Village/Town Zip Code County Township

3. Mailing address (P.O. Box) City/Village/Town, State Zip Code 4. Email (Optional)

5. Former Registration Address: (include City and State and Zip Code) Former County 6.Former Name: (if changed)

7. Date of Birth: MM/DD/YY 9.Home telephone number including 10.ID number - check the applicable box and provide the appropriate number
area code (optional) IL Driver's License or, if none, Sec. of State ID or
Last 4 digits of Social Security Number
8. Sex (circle one) ( ) - I have none of the above-listed identification numbers.
M F
11. Voter Affidavit - Read all statements and sign within the box to the right. This is my signature or mark in the space below.
I swear or affirm that:
• I am a citizen of the United States;
• I will be at least 18 years old on or before the next election
(or the next General or Consolidated Election);
• I will have lived in the State of Illinois and in my election precinct at least
30 days as of the date of the next election;
• The information I have provided is true to the best of my knowledge
under penalty of perjury. If I have provided false information, then I may be Today's Date: / /
fined, imprisoned, or if I am not a U.S. citizen, deported from or refused
entry into the United States.
12. If you cannot sign your name, ask the person who helped you fill in this form to print their name, address and telephone number.
Name of person assisting. Full Address Telephone No.
 Back of SBE No.R-19

YOUR ADDRESS

PUT
FIRST
CLASS
STAMP
HERE

MAIL TO: DANVILLE EXECUTIVE COMMISSION, EXECUTIVE DIRECTOR

201 NORTH VERMILION STREET
DANVILLE, IL 61832

CHANGE OF ADDRESS

PCT WARD CODE ADDRESS CITY ZIP COUNTY DATE CLERK

SUSPENSION, CANCELLATION AND REINSTATEMENT

DATE EXPLAIN CLERK DATE EXPLAIN CLERK

To Election Judges Voting Record 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26

For Primary, mark Primary
D for Democrat General
R for Republican NonPartisan
for all other
elections markV Special