ABSENTEE BALLOT APPLICATION
NOVEMBER 3, 2020 – GENERAL ELECTION
VOTER’S NAME: DATE OF BIRTH:
LAST FOUR DIGITS OF SSN: PHONE NUMBER: E-MAIL:
ADDRESS: CITY: ZIP CODE:
Reason for requesting an absentee ballot (check ONE):
_____ Absence on Election Day from the jurisdiction of the election authority in which I am registered
_____ Incapacity or confinement due to illness or physical disability, including caring for a person who is incapacitated or confined
due to illness or disability. (No Notary Required)
_____ Religious belief or practice
_____ Employment as an election authority or by an election authority at a location other than my polling place
_____ Incarceration, although I have retained all the necessary qualifications for voting
_____ Certified participation in the address confidentiality program established under sections 589.660 to 589.681 because of
safety concerns
_____ I have contracted or am in an at-risk category for contracting or transmitting severe acute respiratory syndrome
coronavirus 2, pursuant to Section 115.277.6, RSMo. (No Notary Required)
At-risk voters are individuals who: • Are 65 years of age or older • Live in a long-term care facility licensed under Chapter 198 RSMo • Have serious heart
conditions• Have chronic lung disease or moderate to severe asthma • Are immunocompromised • Have chronic kidney disease and are undergoing dialysis
• Have liver disease • Have diabetes
If you choose one of the above reasons, this form may be returned: BY EMAIL to BOECAbsentee@stlouisco.com
BY FAX to 314-615-1998, BY MAIL to 725 Northwest Plaza Drive, St. Ann, MO 63074, OR IN PERSON
_____ MAIL-IN BALLOT REQUEST
This form for a mail-in ballot must be delivered by U.S. mail or in person to the St. Louis County Board of Election Commissioners,
725 Northwest Plaza, St. Ann, MO 63074. A mail-in ballot will only be accepted by the St. Louis County Board of Election
Commissioners through the U.S. mail.
Address to which ballot is to be mailed (if different than above):
A
DDRESS: CITY:
STATE: ZIP CODE:
SIGNATURE OF VOTER DATE
SIGNATURE OF PERSON SUBMITTING APPLICATION (if other than voter)
RELATIONSHIP TO VOTER:
_
DATE
PHONE NUMBER:
If you registered by mail and this is your first time voting, you must provide a copy of either: (1) an ID issued by the Federal Government, state of
Missouri, or a local election authority; (2) ID issued by a Missouri institution (public or private) of higher education; or (3) a current utility bill, bank
statement, paycheck, government check or other government document that contains your name and address.
This application must be received by 5:00 p.m. on October 21
st
at the St. Louis County Board of Election Commissioners.
For Absentee Information, visit www.stlouisco.com/yourgovernment/ElectionBoard or call 314-615-1833 / 314-615-1884 (TTY)
2020-06-30
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