Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth Eligibility Operations Memo 12-07 November 1, 2012 TO: MassHealth Eligibility Operations Staff FROM: Amy Andrade, Director, Member and Provider Services RE: MassHealth Responsibilities under the National Voter Registration Act and the Help America Vote Act Introduction This memo outlines the procedures MassHealth must use to ensure that MassHealth applicants and members are offered the opportunity to register to vote as required by the National Voter Registration Act (NVRA), the Help America Vote Act, and related state law. This memo also identifies the appropriate forms to be used in association with the voter registration process and related use and retention requirements. This memo replaces Eligibility Operations Memo 09-15, issued September 1, 2009. Voter Registration Under federal law, MassHealth is required to assist applicants and members to register to vote and to maintain specified records verifying this process. MassHealth is responsible for offering voter registration assistance to applicants and members at application, annual redetermination, or change of address. In addition, MassHealth must provide the same degree of help in filling out the voter registration form as is offered with a MassHealth application or review form. MassHealth may not coerce anyone to register to vote or attempt to persuade anyone to make any particular voting choices. No statements or actions by MassHealth should lead the individual to believe MassHealth services will be affected by the individual’s decision about whether to register to vote. Voter Eligibility MassHealth is not responsible for determining an individual’s eligibility for voter registration. The local election official determines the registration status and mails an Acknowledgement Notice to every applicant with information that may include registration status and location of the polling place. Registration Material Each MassHealth Enrollment Center (MEC) must have the following voter registration material: -Declination Forms; -Massachusetts Official Voter Registration Forms (sometimes referred to as voter registration affidavits); -Massachusetts Official Mail-In Voter Registration Forms; -Secretary of State’s Voter Registration Workbook; and -Request for Secretary of State Election Forms. Posting Requirement The following items must be posted at all MECs: -a copy of M.G.L., chapter 56, sections 7, 8, and 9; and -a “Register to Vote Here” poster. Declination Form The Secretary of State’s Declination Form is required by the NVRA and MEC staff must offer it to every individual who applied in person for services, redetermination of benefits, or change of address and declines assistance registering to vote. MassHealth must keep Declination Forms for at least 22 months to demonstrate compliance with the NRVA, and thereafter as specified by applicable state document retention policies. Part A: This part of the form remains attached to the book of Declination Forms. It states the individual’s choice about voter registration, such as if he or she would like to register or is already registered. If the individual needs to change a registered name, address, or party enrollment, he or she should answer “Yes.” Part B: This is the agency record and remains attached to the book of Declination Forms. It does not record the name of the applicant or member, but records the response to the question in Part A. Part C: This is the copy for the applicant or member. MEC staff must detach and give it to every individual who applies in person for services, redetermination of benefits, or change of address and who completes Part A. Voter Registration Forms There are two official voter registration forms. The Massachusetts Official Voter Registration Form (also referred to as the voter affidavit) is currently a two-part form. It is offered to and completed by an individual who wants to register to vote or change a name, address, or party enrollment in person while in the MEC. The Massachusetts Official Mail-In Registration Form is available in English, Spanish, Russian, Chinese, Vietnamese, Portuguese, Haitian- Creole, Cape Verdean, and Khmer. Each MEC must maintain sufficient supplies of each, depending on the needs of the communities served. Voter Registration Process at the MEC If the individual completes the two-part Official Voter Registration Form, MEC staff must give the individual the yellow copy along with Part C of the Declination Form. This sheet is the only proof that the individual has filled out the registration form until the local election official receives the original copy from MassHealth. Information to help individuals complete specific sections of the Official Voter Registration Form * Sections 1 through 3 — self-explanatory * Section 4 — must not provide a post office box * Sections 5 and 6 — self-explanatory * Section 7 — identification number -federal law requires a valid and current Massachusetts driver’s license to register to vote; or -if no license, the last four digits of the social security number; or -if neither, “none” must be entered in the box * Sections 8 and 9 — self-explanatory Note: It is not appropriate for MEC staff to explain or help the individual choose the party enrollment. * Section 10 — if never registered to vote, leave this section blank * Section 11 — if physically unable to complete the form, the assisting person must complete the form, sign it, and record his or her name on the form. A telephone number is optional. * Sections 12 through 14 — self-explanatory * Agency Designation Code — enter the code BBA MassHealth staff must enter the code BBA in the Agency Designation Code section in the lower right of the two-part form. Note that currently there is no designated spot for this information on the mail-in form, but the Secretary of State’s office instructs agencies to add the code to the bottom right corner of the mail-in form. This masks the identity of the agency submitting the form to protect the privacy of the MassHealth applicant or member. MEC staff must mail the Official Voter Registration Form to the appropriate city or town local election official within five calendar days after the individual completes the form. The mailing address for each city and town is listed on the Massachusetts City and Town Directory page of the Massachusetts Election Division website at www.sec.state.ma.us/ele/eleclk/clkidx.htm. Record Keeping Each MEC must have a system for maintaining the Declination Forms — Parts A and B —and mailing the Voter Registration Forms to the appropriate local election official. Attachments The following documents are included with this memo: * Declination Forms; * Massachusetts Official Voter Registration Forms (sometimes referred to as voter registration affidavits); * Massachusetts Official Mail-In Voter Registration Forms; and * a copy of M.G.L., chapter 56, sections 7, 8, and 9. Questions If you have any questions about this memo, please have your MEC designee contact the Policy Hotline. Declination Form William Francis Gaivin Secretary of the Commonwealth PARTA If you are not registered to vote where you live now and you are eligible to register to vote would you like to apply to register to vote here today? I_ I Yes L_ No I__ Already registered where I live now (If you are registered to vote where you live now and have not changed your address it is not necessary to register to vote again.) Please, sign your name here:_______________________________________Date:_____________ If you do not check any box, you will be considered to have decided not to register to vote at this time. PART B: Use is optional I __I Registered to vote __Did not register to vote __Already registered where I live now For agency use only: Agency staffsignature:___________________________________________Date:___________ Tear along this perforated line and give to applicant. PART C / APPLICANT COPY: Please keep this for your personal, records. * Applying to register or declining to register ro vore will not affect the amount of assistance that you will be provided by this agency. • If you would like help 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. If you believe that someone has interfered with your right to register or to decline to register to vote, your right to privacy in deciding whether to register or in applying to register to vote, or your right to choose your own political party or other political preference, you may file a complaint with the Secretary of the Commonwealth, Elections Division, One Ashburton Place, Room 1705, Boston, MA 02108; telephone 617-727-2828 or toll free 1-800-462-8683. To register to vote in Massachusetts you must be a U.S. citizen, a resident of Massachusetts and at least 18 years of age on or before the next election. If you are registering to vote at an agency, the fact that you register or refuse to register to vote will remain confidential and will be used only for voter registration purposes and the office at which you register will remain confidential And be used only for voter registration purposes. Penalty for Illegal Registration: Fine of not more than $10,000 or imprisonment for not more than five years or both. (MGL c56 s8). William Francis Galvin, Secretary of the Commonwealth Massachusetts Official Voter Registration Form Check all that apply: 1 Are you a Citizen of the United States of America? Yes No Will you be 18 years of age or older on or before Election Day? Yes No NOTE: If you checked "no" to either of these questions, do not complete this form. 2 Full name: Miss Ms. Mrs. Mr. last name first name middle name or initial Jr. Sr. II III IV (circle one if appropriate) 3 Former name (if applicable): Miss Ms. Mrs. Mr. last name first name middle name or initial Jr. Sr. II III IV (circle one if appropriate) 4 Address where you live now (street number, street name, rural route number and box number): apartment number city or town zip code plus 4 digit 5 Address where you receive all your mail (if different from #4): (street number, street name, rural route number and box number): apartment number city or town zip code plus 4 digit 6 Date of birth: month day year 7 Identification #: license # or last four digits of your Social Security number 8 Telephone (optional): ( ) Check if unlisted 9 Party enrollment or designation (check one): Democratic Republican Libertarian No Party (unenrolled) Political Designation (not a political party) 10 Address at which you were last registered to vole: (street number, street name, rural route number and box number): apartment number city or town zip code plus 4 digit 11 If the applicant is unable to sign this form, give the name, address and telephone number (optional) of the person who is helping the applicant: Name Address telephone number (optional) 12 I hereby swear (affirm) that I am the person named above, that the above information is true, that I AM A CITIZEN OF THE UNITED STATES, that I am not a person n under a guardianship which prohibits my registering to vote that I am not temporarily or permanently disqualified by law from voting because of corrupt practices in respect to elections that I am not currently incarcerated for a felony conviction, and that I consider this residence to be my home. Signed under the penalty of perjury. 13 Today's date: month day year 14 Signed: Sign your name here. Massachusetts Offcial Mail-In Voter Registration Form How to use this form 1. Check all the boxes that apply to you. 2. Print your name: last name, frst name, middle name or initial. 3. Print your former name, if applicable. 4. Print the address where you live now: number and street name or rural route number and box number (do not provide a post offce box number), apartment number, city or town and full zip code. Use the map† at right if you cannot otherwise identify your address. 5. Print the address where you receive all your mail, if it is different from the address entered on #4. 6. Print your date of birth: month, day and year. 7. Federal law requires that you provide your driver’s license number to register to vote. If you do not have a current and valid Massachusetts driver’s license, you must provide the last four digits of your social security number. If you have neither, you must write “none” in the box. 8. It is optional to provide your telephone number. If you include your telephone number and do not check “unlisted” it will be a public record. 9. Check a party, ‘no party’ or print a political designation (not a party). 10. Print the address where you were last registered to vote. 11. If a person is helping you because you are physically unable to sign this form, that assisting person must print his or her name and address and has the option to print his or her telephone number. 12. Read the oath. 13. Print today’s date. 14 . Sign your name. This form may be mailed or hand-delivered to your city or town hall. If mailed, fold the form, tape it closed, place a frst class stamp on it, print your city or town name and zip code for that city or town hall and drop into any mailbox. Help America Vote Act William Francis Galvin Secretary of the Commonwealth You can use this form to: • register to vote in Massachusetts; and/or • change your name or address for voter registration only; and/or • join a party, change from one party to another or leave a party. To register to vote in Massachusetts you must: • be a U.S. citizen; and • be a Massachusetts resident; and • be at least 18 years old on or before the next election. Penalty for illegal Registration: Fine of not more than $10,000 or imprisonment for not more than fve years or both. -Massachusetts General Laws, chapter 56 section 8. ntifcation To Be Provided Section 7 requires you to include your driver’s license number or the last 4 digits of your social security number on this application. This information will be verifed through the Registry of Motor Vehicles and the Commissioner of Social Security. If the information cannot be verifed or you do not provide this information, you must provide identifcation either with this application or at your polling location when you go to vote. Suffcient identifcation includes a copy of a current and valid photo identifcation, current utility bill, bank statement, government check, paycheck or other government document showing your name and address. north west east south †Using landmarks, draw the location of the place whe Using landmarks, draw the location of the place where you live if you cannot describe that location as a number and street or as a rural route and box number. Follow the instructions listed above for proper delivery. 1 check all that apply: Are you a Citizen of the United States of America? ? Yes D No Will you be 18 years of age or older on or before Election Day? ? Yes ? No NOTE: If you checked “no” to either of these question, do not complete this form._________________ 2 Full name: Miss Ms. Mrs. Mr. last name first name middle name or initial Jr. Sr. II III IV (circle one if appropriate) 3 Former name (if applicable): Miss Ms. Mrs. Mr. last name first name middle name or initial Jr. Sr. II III IV (circle one if appropriate) 4 Address where you live now (street number, street name, rural route number and box number): apartment number city or town zip code plus 4 digit 5 Address where you receive all your mail (if different from #4): (street number, street name, rural route number and box number): apartment number city or town zip code plus 4 digit 6 Date of birth: month day year 7 Identification #: license # or last four digits of your Social Security number 8 Telephone (optional): ( ) Check if unlisted 9 Party enrollment or designation (check one): Democratic Republican Libertarian No Party (unenrolled) Political Designation (not a political party) 10 Address at which you were last registered to vole: (street number, street name, rural route number and box number): apartment number city or town zip code plus 4 digit 11 If the applicant is unable to sign this form, give the name, address and telephone number (optional) of the person who is helping the applicant: Name Address telephone number (optional) 12 I hereby swear (affirm) that I am the person named above, that the above information is true, that I AM A CITIZEN OF THE UNITED STATES, that I am not a person n under a guardianship which prohibits my registering to vote that I am not temporarily or permanently disqualified by law from voting because of corrupt practices in respect to elections that I am not currently incarcerated for a felony conviction, and that I consider this residence to be my home. Signed under the penalty of perjury. 13 Today's date: month day year 14 Signed: Sign your name here. Check to make sure that you have completed all the information on the voter registration affdavit on the opposite side! This form must be received by the local Board of Registrars or Election Commission or postmarked on or before the deadline for voter registration (listed below) for that election, primary, preliminary or town meeting. DEADLINES FOR VOTER REGISTrATION To participate in... state primaries state elections city and town preliminaries city and town elections regularly scheduled town meetings You must register... at least 20 days before special town meetings at least 10 days before If you do not hear from your local election offcials in 2 or 3 weeks, please call them! Fold along dotted line. Return Address number and street MA city or town zip cod Place First Class Stamp Here Board of Registrars or Election Commission City or Town Hall MA name YOUR CITY OR TOWN ZIP CODe FOR CITY OR TOWN HALL General Laws of Massachusetts Chapter 56. Violations of election laws PENALTIES FOR OFFENCES CONCERNING ASSESSMENT, LISTING AND REGISTRATION OF VOTERS Section 7. Aiding or Abetting fAlse AffidAvits or oAths. Whoever aids or abets a person in knowingly or wilfully making a false affdavit, taking a false oath or signing a false certifcate relative to the qualifcations of any person for listing or registration shall be punished by a fne of not more than one thousand dollars or by imprisonment for not more than one year. Section 8. illegAl registrAtion. Whoever causes or attempts to cause his name to be registered, knowing that he is not a qualifed voter in the place of such registration or attempted registration; whoever registers or attempts to register under a name other than his own; whoever represents or attempts to represent himself as some other person to an election commissioner, registrar or assistant registrar; whoever gives a false answer to an election commissioner, registrar or assistant registrar respecting any matter relating to his registration or his right to vote; whoever otherwise illegally registers or attempts to register; or whoever aids or abets any other person in doing any of the acts above mentioned, shall be punished by a fne of not more than ten thousand dollars or by imprisonment for not more than fve years, or both. Section 9. Misconduct At registrAtion. Whoever refuses to obey the lawful orders or directions of an election commissioner, registrar or assistant registrar, or interrupts or disturbs the proceedings at any registration shall be punished by a fne of not more than one hundred dollars. VR-P (04/09)