Date of Birth
State Zip Code
X
X
2020 STATE ABSENTEE BALLOT REQUEST FORM
(Read the instructions before completing this form. Items in red are required.)
FRAUDULENTLY OR FALSELY COMPLETING THIS FORM IS A CLASS I FELONY UNDER CHAPTER 163 OF THE NC GENERAL STATUTES
1 Voter Information
Last Name
First Name
Middle Name
Suffix
/
Previous Last Name Previous First Name
Previous Middle Name
NC DL or ID Number
Last Four Digits of
Social Security number
Current NC Residential Street Address
City County
Have you lived at this address for
30 or more days? Yes
No
If “No”, date moved?
/ /
Provide your mailing address if you do not receive mail at your
residential address.
2
Absentee Voting Information
Select the date of the election event for which a by-mail absentee
ballot is being requested. You may only select one election event per request form.
Election Date (select one)
Absentee Mailing Address (where you would like your ballot sent)
Mailing City State Zip Code
If you are requesting an absentee ballot for a partisan
primary, and you are not affiliated with a political party
(Unaffiliated), select a primary ballot preference.
Democratic
Libertarian
Republican
Nonpartisan
Near Relative or Legal Guardian Request: If you are requesting an absentee ballot on behalf of a near relative or for someone for whom you are the
legal guardian, provide your name, relationship to the voter (see instructions), address and contact information.
Near Relative or Legal Guardian’s Name Your Relationship to Voter
Near Relative or Legal Guardian’s Address
City
State
Zip Code
Voter Assistance: If the voter received assistance completing this form due to blindness, disability, or inability to read or write and no near relative or
legal guardian of the voter was available, list the name and address of the person assisting the voter with completing this form.
Voter Assistant’s Name
Address
City
State
Zip Code
If voter is a patient in a hospital, clinic, nursing home or rest home, does voter need assistance with voting and returning the ballot? Yes No
If Yes, what is the name and address of the hospital or facility?
3
Military & Overseas
Are you an absentee military or overseas voter? If so, select the best option below that describes your absentee status:
Member of the Uniformed Services or Merchant Marine on active duty or eligible spouse/dependent and currently absent from county of residence
U.S. citizen outside the United States
Provide the address where you are currently stationed or living overseas. Send your ballot by mail? (provide address)
Send your ballot by email? (provide email address)
Send your ballot by fax? (provide #)
4
Voter’s Signature
Near Relative or Legal Guardian Signature (if applicable)
Date
Date
SBOE 2020.03
OR
E-mail Phone
Please provide your email address or a telephone number in case we have a question concerning this request.
November 3, 2020
Check if you would like to request absentee ballots for all elections
held during this calendar year in which you are eligible to vote due to
continued or expected illness or disability
.
ROWAN COUNTY BOE - 1935 JAKE ALEXANDER BLVD W D10
S
ALISBURY, NC 28147 704-216-8140 (p) 704-216-8145 (f)
2020 STATE ABSENTEE BALLOT REQUEST FORM - INSTRUCTIONS
To request an absentee ballot, a registered voter or voter’s near relative or verifiable legal guardian must complete and sign this
form. If you are not registered to vote in your county of residence, you must register to vote no later than 25 days prior to the date
of the election. You can submit a voter registration form with this request. Prior to completing the form, review the instructions
below.
1
Voter
Information
Provide your full legal name.
Provide your date of birth.
Provide one of the following:
o North Carolina driver license number or non-operator identification card number; or
o last four digits of your Social Security number
Provide your current residential address. (Your North Carolina residential address is required so you get the
correct ballot.)
Please provide your email address or a telephone number in case we have a question concerning this request.
Note: This form will be used to update the above information if it is different from your voter record.
2
Absentee
Voting
Information
Indicate the election you are requesting an absentee ballot for and the address where you would like your ballot
mailed. Also, indicate if you would like to request absentee ballots for all elections held during this calendar year
in which you are eligible to vote due to continued or expected illness or disability.
Partisan Primary Requests: If you are requesting a by-mail ballot for a partisan primary and you are not affiliated
with a political party, provide your primary ballot preference. You may select a ballot of one of the recognized
political parties that allow unaffiliated voters to participate in their primary or a nonpartisan ballot style. In a given
primary, not all ballot choices may be available. Contact your county board of elections to determine available
ballot options.
Information on Who Can Assist You in Completing this Request Form
All voters: All voters are entitled to assistance from their near relative or verifiable legal guardian. If you are a
near relative or verifiable legal guardian requesting an absentee ballot on behalf of the voter, you must list your
name and address. A near relative is defined as the voter’s:
spouse
parent
grandchild
daughter-in-law
stepchild
brother
grandparent
mother-in-law
son-in-law
sister
child
father-in-law
stepparent
Voters Who Are Blind, Disabled, or Unable to Read or Write: If a voter needs assistance in completing the
written request form due to blindness, disability, or inability to read or write and there is not a near relative or legal
guardian available to assist that voter, the voter may request some other person give assistance. If another person
assists in completing the written request form, that person's name and address must be listed on this form.
Voters Who Are Patients in any Hospital, Clinic, Nursing Home, or Rest Home (“Facility”): If a registered
voter is a patient in a Facility in North Carolina, a member of a Multipartisan Assistance Team (MAT) authorized
by the county board of elections can assist the voter in completing the request form. Please contact the county
board of elections to request assistance from a MAT. It is unlawful for any owner, manager, director, or employee
of the Facility OTHER than the voter's near relative, verifiable legal guardian, or member of a MAT to request an
absentee ballot on behalf of the voter. If neither the voter’s near relative nor verifiable legal guardian is available,
and a MAT is not available within seven calendar days of a telephonic request for assistance, the voter may obtain
assistance from anyone who is not (1) an owner, manager, director, or employee of the Facility; (2) an elected
official; (3) a candidate; or (4) an officeholder in a political party or a campaign manager or treasurer for a candidate
or political party.
3
Military &
Overseas
Requests
Complete this section if you are requesting an absentee ballot because you are uniformed services personnel or a
dependent or spouse of uniformed services personnel and you are absent from your North Carolina county of
residence due to military service. You are also eligible to complete this section if you are a civilian and can claim North
Carolina as your state of residence and you are currently outside of the United States.
Special Note: Military and Overseas voters may email (absentee@ncsbe.gov) or fax (919) 715-0351 a signed
copy of this form.
4
How to
return this
form
This form must be signed by either the voter or the voter’s near relative/legal
guardian. Absentee request forms may only be returned by the voter, the voter’s
near relative or verifiable legal guardian or a MAT. The form must be
emailed, faxed, hand delivered or by the U.S. Postal Service or other
designated delivery service (DHL, FedEx, or UPS) to the voter’s county board
of elections. A completed absentee request form must be received
by the county board of elections not later than 5:00 P.M. on the Tuesday
before the election.
Rowan County BOE
1935 Jake Alexander Blvd W
D10
Salisbury, NC 28147
704-216-8140 phone
704-216-8145 fax
rowan.boe@rowancountync.gov