Tex. Election Code § 20.003

The officially prescribed form for a declination of a voter registration must include:

(1) spaces for the person's signature and printed name and the date of signing;

(2) the following question, followed by appropriate boxes preceding "YES" and "NO": "If you are not registered to vote where you live now, would you like to apply to register to vote here today?";

(3) 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.";

(4) the statement: "IF YOU HAVE NOT CHECKED EITHER BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER TO VOTE AT THIS TIME.";

(5) the statement: "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.";

(6) the statement: "If you believe that someone has interfered with your right to register or to decline to register to vote or with your right to privacy in deciding whether to register or in applying to register to vote, you may file a complaint with the Elections Division of the Office of the Secretary of State, P.O. Box 12060, Austin, Texas 78711.";

(7) a statement that if the applicant declines to register to vote, that fact will remain confidential and will be used only for voter registration purposes;

(8) a statement that if the applicant does register to vote, information regarding the agency or office to which the application is submitted will remain confidential and will be used only for voter registration purposes; and

(9) a space for indicating that the applicant refused to sign the declination or kept the application to personally submit it to the voter registrar.