3. City of Chicopee
5. City of Chicopee Registrar of Voters City Hall 274 Front Street Chicopee, MA 01013-2885
6. IMPORTANT LEGAL DOCUMENT ANNUAL CITY CENSUS
8. IMPORTANT: General Laws of Massachusetts mandate an annual street listing of residents as of January 1 each year. Compliance with this requirement provides proof of residence to protect your voting privilege, veteran’s bonuses, use of the Chicopee Landfill, Social Security and related benefits. Please list ALL family or household members (age 3 and up) whose legal residence is the same. Include any member of the family in military service, away at school or confined to a rest home. For assistance, call CITY REGISTRAR AT 413-594-1550
10. Street Address*
11. 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.
13. Apt
14. City*
15. State
16. Zip*
18. TELEPHONE
19. WARD
20. PRECINT
24. First Name*
25. Last Name*
26. Active Voter*

    1. Y
    2. N
28. Mail To?*

    1. Y
    2. N
29. Gender? M/F*

    1. M
    2. F
30. Date of Birth mm/dd/yyyy*
    Date of Birth mm/dd/yyyy
32. Occupation*
33. Nationality (if not U.S. citizen)
34. U.S. Veteran?*

    1. Y
    2. N
35. Public Safety?*

    1. Y
    2. N
39. First Name
40. Last Name
41. Active Voter?

    1. Y
    2. N
43. Mail to?

    1. Y
    2. N
44. Gender

    1. M
    2. F
45. Date of Birth mm/dd/yyyy
    Date of Birth mm/dd/yyyy
47. Occupation
48. Nationality (if not U.S. citizen)
49. U.S. Veteran?

    1. Y
    2. N
50. Public SAfety?

    1. Y
    2. N
54. First Name
55. Last Name
57. Mail to?

    1. Y
    2. N
58. Gender

    1. M
    2. F
59. Date of Birth mm/dd/yyyy
    Date of Birth mm/dd/yyyy
61. Occupation
62. Nationality (if not U.S. citizen)
63. U.S. Veteran?

    1. Y
    2. N
64. Public Safety?

    1. Y
    2. N
68. Name of person submitting this form.*
69. Date:*
    Date:
70. Enter Number of Dogs:*
72. Email*
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74. 1. Receive an email copy of this form.
75. Email address

    This field is not part of the form submission.

76. Submit Submit and Print

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