(1) Each election officer shall ensure that provisional ballot envelopes are printed in substantially the following form: "AFFIRMATIONAre you a citizen of the United States of America? Yes NoWill you be 18 years old on or before election day? Yes NoIf you checked "no" in response to either of the two above questions, do not complete this form. Name of Voter _________________________________________________________ First Middle Last Driver License or Identification Card Number _________________________________ State of Issuance of Driver License or Identification Card Number _________________ Date of Birth ___________________________________________________________ Street Address of Principal Place of Residence ______________________________________________________________________ City County State Zip Code Telephone Number (optional) ______________________________________________ Last four digits of Social Security Number ____________________________ Last former address at which I was registered to vote (if known) ______________________________________________________________________ City County State Zip Code Voting Precinct (if known) _________________________________________________ I, (please print your full name)__________________________do solemnly swear or affirm: That I am eligible to vote in this election; that I have not voted in this election in any other precinct; that I am eligible to vote in this precinct; and that I request that I be permitted to vote in this precinct; and Subject to penalty of law for false statements, that the information contained in this form is true, and that I am a citizen of the United States and a resident of Utah, residing at the above address; and that I am at least 18 years old and have resided in Utah for the 30 days immediately before this election.Signed ______________________________________________________________________Dated ______________________________________________________________________ In accordance with Section 20A-3-506, wilfully providing false information above is a class B misdemeanor under Utah law and is punishable by imprisonment and by fine." "The portion of your voter registration form that lists your driver license or identification card number, social security number, and email address, and the day of your month of birth, is a private record. The portion of your voter registration form that lists your month and year of birth is a private record, the use of which is restricted to government officials, government employees, political parties, or certain other persons. You may apply to the lieutenant governor or your county clerk to have your entire voter registration record classified as private." "CITIZENSHIP AFFIDAVIT Name: Name at birth, if different: Place of birth: Date of birth: Date and place of naturalization (if applicable): I hereby swear and affirm, under penalties for voting fraud set forth below, that I am a citizen and that to the best of my knowledge and belief the information above is true and correct. ____________________________ Signature of Applicant In accordance with Section 20A-2-401, the penalty for willfully causing, procuring, or allowing yourself to be registered to vote if you know you are not entitled to register to vote is up to one year in jail and a fine of up to $2,500."

(2) The provisional ballot envelope shall include: (a) a unique number; (b) a detachable part that includes the unique number; and (c) a telephone number, internet address, or other indicator of a means, in accordance with Section 20A-6-105.5, where the voter can find out if the provisional ballot was counted.

(a) a unique number;

(b) a detachable part that includes the unique number; and

(c) a telephone number, internet address, or other indicator of a means, in accordance with Section 20A-6-105.5, where the voter can find out if the provisional ballot was counted.