Fillable 1670 - EL-121 Application for Absentee Ballot (2018-10) indef conf

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1670 - EL-121 Application for Absentee Ballot (2018-10) indef conf

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EL-121 | Rev 2018-10 | Wisconsin Elections Commission, P.O. Box 7984, Madison, WI 53707-7984 | 608-266-8005 | web: elections.wi.gov | email: elections@wi.gov
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Wisconsin Application for Absentee Ballot
(Municipal Clerk) If in-person
voter, check here:
Absentee ballots ma
y
also be requested at M
y
Vote.wi.
g
ov
Confidential Elector ID#
(HINDI - sequential #) (Official Use Only)
WisVote ID #
(Official Use Only)
Ward No.
Detailed instructions for completion are on the back of this form. Return this form to your municipal clerk when completed.

You must be registered to vote before you can receive an absentee ballot. You can confirm your voter registration at https://myvote.wi.gov
PHOTO ID REQUIRED, unless you qualify for an exception. See instructions on back for exceptions.
VOTER INFORMATION
1
Municipality
County
2
Last Name
First Name
Middle Name
Suffix
(e.g. Jr, II, etc.)
Date of Birth
(MM/DD/YYYY)
Phone
Fax
Email
3
Residence Address: Street Number & Name
Apt. Number
City
State & ZIP
4
Fill in the appropriate circle – if applicable (see instructions for definitions): Military Permanent Overseas Temporary Overseas
I PREFER TO RECEIVE MY ABSENTEE BALLOT BY:
(Ballot will be mailed to the address above if no preference is indicated.
Absentee ballots may not be forwarded.)
5
MAIL
Mailing Address: Street Number & Name
VOTE IN
CLERK’S
OFFICE
Apt. Number
City
State & ZIP
Care Facility Name (if applicable)
C / O (if applicable)
FAX
Fax Number
Voter must have a computer and printer when
receiving a ballot by fax or email. Voted ballots
must be returned by mai
l.
EMAIL
Email Address
I REQUEST AN ABSENTEE BALLOT BE SENT TO ME FOR:
(mark only one)
6
The election(s) on the following date(s): ____________________________________________________________________________
All elections from today’s date through the end of the current calendar year (ending 12/31).
For indefinitely-confined voters only: I certify that I am indefinitely confined because of age, illness, infirmity or disability and
request absentee ballots be sent to me automatically until I am no longer confined, or I fail to return a ballot. Anyone who makes false
statements in order to obtain an absentee ballot may be fined not more than $1,000 or imprisoned not more than 6 months or both.
Wis. Stats. §§ 12.13(3)(i), 12.60(1)(b).
TEMPORARILY HOSPITALIZED VOTERS ONLY
(please fill in circle)
7
I certify that I cannot appear at the polling place on election day because I am hospitalized, and appoint the following person to serve as
my agent, pursuant to Wis. Stat. § 6.86(3).
Agent
Last Name
Agent
First
Name
Agent
Middle
Name
AGENT: I certify that I am the duly appointed agent of the hospitalized absentee elector, that the absentee ballot to be received by me is
received solely for the benefit of the above named hospitalized elector, and that such ballot will be promptly transmitted by me to that elector
and then returned to the municipal clerk or the proper polling place.
Agent
Signature
X
Agent
Address
ASSISTANT DECLARATION / CERTIFICATION
(if required)
I certify that the application is made on request and by authorization of the named elector, who is unable to sign the application due to physical disability.
Agent
Signature
X
Today’s Date
VOTER DECLARATION / CERTIFICATION
(required for all voters)
I certify that I am a qualified elector, a U.S. Citizen, at least 18 years old, having resided at the above residential address for at least 10 consecutive days
immediately preceding this election, not currently serving a sentence including probation or parole for a felony conviction, and not otherwise disqualified
from voting. Please sign below to acknowledge that you have read and understand the above.
Voter
Signature
X
Today’s Date
Instructions
Town
Village
City
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EL-121 | Rev 2018-10 | Wisconsin Elections Commission, P.O. Box 7984, Madison, WI 53707-7984 | 608-266-8005 | web: elections.wi.gov | email: elections@wi.gov
Wisconsin Application for Absentee Ballot Instructions
General Instructions: This form should be submitted to your municipal clerk, unless directed otherwise.
This form should only be completed by registered voters; if you are not a registered voter or military elector, please submit a Voter
Registration Application (EL-131) with this form.
Photo ID requirement: If you will receive your absentee ballot by mail, and have not previously provided a copy of acceptable photo
ID with a prior by-mail absentee ballot request, a copy of photo ID must accompany this application. You may submit your application
and a copy of your ID by mail, fax or email. In-person voters must always show acceptable photo ID.
The following documents are acceptable Photo ID (For specific information regarding expired documents visit http://bringit.wi.gov.)
State of WI driver license or ID card
Military ID card issued by a U.S. uniformed service
Photo ID issued by the federal Dept. of Veterans Affairs
University, college or tech college ID and enrollment verification
U.S. passport booklet or card
Certificate of Naturalization
WI DOT DL or ID card receipt
Citation/Notice to revoke or suspend WI DL
ID card issued by federally recognized WI tribe
In lieu of photo ID, the voters listed below may satisfy the voter ID requirement by the following means:
Electors who are indefinitely confined (see Section 6) – the signature of a witness on the Absentee Certificate Envelope.
Electors residing in care facilities served by Special Voting Deputies – the signatures of both deputies on the envelope.
Electors residing in care facilities not served by Special Voting Deputies – the signature of an authorized representative of the
facility. If the elector is also indefinitely confined, the elector does not need a representative of the facility to sign.
Military, Permanent Overseas and Confidential Electors – Exempt from the photo ID requirement.
1
Indicate the municipality and county of residence. Use the municipality’s formal name (for example: City of Ashland, Village of Greendale,
or Town of Albion).
2
Provide your name as you are registered to vote in Wisconsin. If applicable, please provide your suffix (Jr, Sr, etc.) and/or
middle name. If your current name is different than how you are registered to vote, please submit a Voter Registration
Application (EL-131) with this form to update your information.
Provide your month, day and year of birth. Remember to use your birth year, not the current year.
3
Provide your home address (legal voting residence) with full house number (including fractions, if any).
Provide your full street name, including the type (eg., Ave.) and any pre– and/or post-directional (N, S, etc.).
Provide the city name and ZIP code as it would appear on mail delivered to the home address.
You may not enter a PO Box as a voting residence. A rural route box without a number may not be used.
4
A “Military elector” is a person, or the spouse or dependent of a person who is a member of a uniformed service or the
merchant marines, a civilian employee of the United States, a civilian officially attached to a uniformed service and serving
outside the United States, or a Peace Corp volunteer. Military electors do not need to register to vote.
A “Permanent Overseas elector” is a person who is a United States citizen, 18 years old or older, who resided in Wisconsin
immediately prior to leaving the United States, who is now living outside the United States and has no present intent to return,
who is not registered in any other location, or who is an adult child of a United States citizen who resided in this state prior to
establishing residency abroad. Permanent Overseas electors will receive ballots for federal offices only and must be registered
to vote prior to receiving a ballot.
A “Temporary Overseas elector” is a person who is a United States citizen, 18 years of age or older, a resident of Wisconsin and is
overseas for a temporary purpose and intends to return to their Wisconsin residence.
5
Fill in the circle to indicate your preferred method of receiving your absentee ballot.
Military and Permanent Overseas voters may request and access their ballot directly at https://myvote.wi.gov.
If no preference is indicated, your absentee ballot will be mailed to your residence address listed in Box 3.
You are encouraged to provide a physical mailing address as backup in case of electronic transmission difficulties. Please only
fill the circle for your preferred means of transmission.
If you are living in a care facility, please provide the name of the facility.
If someone will be receiving the ballot on your behalf, please list them after C/O. Please note: The absentee elector is still
required to vote their own ballot, although they may request assistance in physically marking the ballot.
6
Select the first option if you would like to receive a ballot for a single election or a specific set of elections.
Select the second option if you would like to have a standing absentee request for any and all elections that may occur in a
calendar year (ending December 31).
Select the third option only if you are indefinitely confined due to age, illness, infirmity or disability and wish to request
absentee ballots for all elections until you are no longer confined or fail to return a ballot for an election.
7
 This section is only to be completed by an elector or the agent of an elector who is currently hospitalized.
 An agent completing this form for a hospitalized elector must provide his/her name, signature and address on this application.
Assistant Signature:
In the situation where the elector is unable to sign the Voter Declaration / Certification due to a physical
disability, the elector may authorize another elector to sign on his or her behalf. Any elector signing an
application on another elector's behalf shall attest to a statement that the application is made on request and
by authorization of the named elector, who is unable to sign the application due to physical disability.
Voter Signature:
By signing and dating this form, you certify that you are a qualified elector, a U.S. citizen, at least 18 years
old, having resided at your residential address for at least 10 consecutive days immediately preceding this
election, not currently serving a sentence including probation or parole for a felony conviction, and not
otherwise disqualified from voting.
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Completed 12 July 2020

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