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Prescribed by Secretary of State
Section 63.001(i), Texas Election Code1/2018

REASONABLE IMPEDIMENT DECLARATION
Instructions: If a voter appears on the official list of registered voters, but does not possess an acceptable form ofphoto identification under Section 63.0101 (a) of the Texas Election Code (which, for voters aged 18‐69, has expired by no
more than four years, and for voters aged 70 or over, is or is not expired, if otherwise valid) (“Acceptable Photo ID”), andcannot reasonably obtain an Acceptable Photo ID, the following steps shall be taken by the election officer to allow thevoter to cast a regular ballot:

1. Present this form to the voter, and ask the voter to provide a copy or original of one of the following formsof identification listed in Section 63.0101(b) of the Texas Election Code:a. a certified domestic (from a U.S. state or territory) birth certificate or a document confirming birth admissible
in a court of law which establishes the voter’s identity (which may include a foreign birth document);b. a current utility bill;c. a bank statement;
d. a government check;e. a paycheck; orf. a government document that shows the voter’s name and an address (which includes the voter’s voter
registration certificate).
NOTE: The address on the identification presented is not required to match the address recorded in
the official list of registered voters.
NOTE: If on Election Day, a presented voter registration certificate indicates that the voter is appearing
at the incorrect polling place, the voter should be directed to the correct polling place.

2. Ask the voter to complete this form by entering their name, and then ask them to review the “Voter’sDeclaration of Reasonable Impediment”, indicate their impediment, and sign their name.

3. Ask the voter to return the completed form to you. Neither you nor the election judge may question the voter
concerning the reasonableness of any claimed impediment. The election judge should enter the date andthen sign on the space provided on the declaration.

4. Either you or the election judge shall fill in the voter’s Voter Unique Identification Number (“VUID”) in the appropriate
box or affix a sticker that contains that information across the box, and note on the combination form that thedeclaration was used by the voter. Either you or the election judge should indicate on the “To Be Completed
By Election Official” form what type of document the voter provided by checking the appropriate box. Either
you or the election judge should fill in the Date of Election and Location fields.

5. Allow the voter to cast a regular ballot.
NOTE: This form may also be used if a voter voted provisionally and does not possess and cannot reasonably obtain an
acceptable form of photo identification, and appears at the county voter registrar’s office within six (6) calendar days after
election day to execute a reasonable impediment declaration and present one of the supporting forms of identification, inaccordance with Section 65.0541 of the Texas Election Code. In that instance, the county voter registrar should follow steps 1
through 4 above, but substitute references to “election judge” with “county voter registrar”, including signing where theelection judge would otherwise sign on the space provided on the declaration.

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Prescribed by Secretary of State
Section 63.001(i), Texas Election Code
1/2018REASONABLE IMPEDIMENT DECLARATIONTO BE COMPLETED BY VOTER
Name: _______________________________________________________________________________VOTER’S DECLARATION OF REASONABLE IMPEDIMENT
A person is subject to prosecution for perjury under Chapter 37, Penal Code, or Section 63.0013 of the Texas Election Code forproviding a false statement or false information on this declaration. By signing this declaration, I swear or affirm underpenalty of perjury that the information contained in this declaration is true, that I am the same individual personally appearing
at the polling place to sign this declaration, and that I face a reasonable impediment to procuring an acceptable form ofphoto identification listed in Section 63.0101(a) of the Texas Election Code.
My reasonable impediment is due to the following reason(s):(Check at least one box below)
Lack of transportation

Disability or illness

Lack of birth certificate or other documents needed to obtain acceptable form of photo ID
Work schedule

Family responsibilities

Lost or stolen identification

Acceptable form of photo ID applied for but not received

The reasonableness of your impediment cannot be questioned.

X _________________________________________
Signature of Voter__________Date
VUID (Voter Unique Identification Number)

Sworn to and subscribed before me this____ day of ______, 20 ___Presiding Judge/ County Voter Registrar (if applicable)_______________________________TO BE COMPLETED BY ELECTION OFFICIAL
The voter provided a copy or original of one of the following forms of identification:_______ Certified copy of a domestic (from a U.S. state or territory) birth certificate or a document confirming
birth admissible in a court of law which establishes the voter’s identity (which may include a foreign birth
document)
Current utility bill
Bank statement
Government check
Government document that shows the voter’s name and an address (including the voter’s voter
registration certificate)
Paycheck
Location: _____________________

Date of Election: __________________________