Your First Name:

Your Last Name:

Phone Number:

Home Address:

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Your Preferred Method of Contact: Phoneemail

State where incident occurred: AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Jurisdiction where incident occurred (city, county, precinct, etc.):

Nature of incident:  Registering to vote Voting machine defect Long lines/wait time at polling place Problem obtaining information/ incorrect information Voter Intimidation Denied paper ballot Absentee ballot problem Identification issue other:

Please describe the incident in as much detail as possible.