A voter registration agency that is an office that provides service or assistance in addition to conducting voter registration shall
(A) distribute with each application for such service or assistance, and with each recertification, renewal, or change of address form relating to such service or assistance
(i) the mail voter registration application form described in section
1973gg–7 (a)(2) of this title, including a statement that
(I) specifies each eligibility requirement (including citizenship);
(II) contains an attestation that the applicant meets each such requirement; and
(III) requires the signature of the applicant, under penalty of perjury; or
(ii) the offices own form if it is equivalent to the form described in section
1973gg–7 (a)(2) of this title,
unless the applicant, in writing, declines to register to vote;
(B) provide a form that includes
(i) the question, If you are not registered to vote where you live now, would you like to apply to register to vote here today?;
(ii) if the agency provides public assistance, the statement, Applying to register or declining to register to vote will not affect the amount of assistance that you will be provided by this agency.;
(iii) boxes for the applicant to check to indicate whether the applicant would like to register or declines to register to vote (failure to check either box being deemed to constitute a declination to register for purposes of subparagraph (C)), together with the statement (in close proximity to the boxes and in prominent type), IF YOU DO NOT CHECK EITHER BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER TO VOTE AT THIS TIME.;
(iv) the statement, If you would like help in 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.; and
(v) the statement, 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 XXXXX., the blank being filled by the name, address, and telephone number of the appropriate official to whom such a complaint should be addressed; and