Village of Farmingdale
ABSENTEE BALLOT APPLICATION – VILLAGE ELECTION
Due to Military Service (Sec. 15-120)
Due to Duties, Occupations, Business, Studies or Vacation (Sec. 15-120)
Due to Illness or Physical Disability (Sec. 15-122)
Due to Permanent Illness or Permanent Disability (Sec. 15-122)
See Reverse Side for Instructions
To the Clerk of the Village of Farmingdale:
, an applicant for an absentee ballot, states as follows:
(Print or type name)
I reside at , and I am a qualified voter of the Village of Farmingdale,
(Street, number, village and zip code)
County of Nassau.
I KNOW OF NO REASON WHY I AM NO LONGER QUALIFIED TO VOTE
MILITARY SERVICE, DUTIES, OCCUPATION, BUSINESS, STUDIES or VACATION
I expect in good faith to be absent from the County of Nassau, State of New York, on the day of the next village election on
, 20 because my duties, occupation, business, studies, military service or vacation require me to be
elsewhere as follows:
1. Explain briefly your position and nature of duties, occupation, studies, military service or business requiring such absence.
If absence is based on vacation, so state and give dates when you expect to begin and end your vacation.
2. Place or places where you expect to be on military service, business, studies or on vacation.
3. Name of employer, if any
(If self-employed or unemployed, so state – If student, give name of school)
4. Address of employer
(If student, give address of school)
5. If this application is based by reason of accompanying your spouse, child or parent: would such spouse, child or parent, if
a qualified voter, be entitled to apply for the right to vote by absentee ballot?
(Yes or No)
,
(Name of such spouse, child or parent) (Relationship to you)
6. If this application is based by reason of being or expecting to be an inmate of a veterans’ hospital, give name and address
of hospital.
7. If application is based on confinement pending trial in a criminal proceeding or for conviction of a crime or offense other
than a felony, give particulars:
DUE TO ILLNESS OR PHYSICAL DISABILITY
I certify that I have been advised by my medical practitioner or Christian Science practitioner:
(Name and address of medical practitioner or Christian Science practitioner)
That I will be unable to appear personally at Village Hall where I am a qualified voter on the day of the next village election
because of my Illness Physical Disability and will be confined at Home, in a Hospital. If hospital confinement
is expected, state name and address of Hospital. (Check appropriate boxes)
(Name of Hospital) (Address of Hospital)
DUE TO PERMANENT ILLNESS OR PERMANENT DISABILITY
I hereby certify that such illness or disability is permanent and request that Absentee Ballots be mailed to me for future
elections without my making further application. The nature of my permanent illness or disability is
ALL APPLICANTS MUST FILL OUT THE FOLLOWING
If application is approved, I request ballot be delivered personally to me or a member of my family or mailed to me at the
following address:
(Print or type)
APPLICANT MUST SIGN BELOW
I CERTIFY THAT THE INFORMATION IN THIS APPLICATION IS TRUE AND CORRECT AND UNDERSTAND THAT
THIS APPLICATION WILL BE ACCEPTED FOR ALL PURPOSES AS THE EQUIVALENT OF AN AFFIDAVIT AND, IF IT
CONTAINS A MATERIAL FALSE STATEMENT, SHALL SUBJECT ME TO THE SAME PENALTIES AS IF I HAD BEEN
DULY SWORN.
Date
Signature of Voter
(If applicant is unable to sign application because of illness or physical disability, the following statement must be executed): By my mark,
duly witnessed hereunder, I hereby state that I am unable to sign my application for an absentee ballot without assistance because I am
unable to write by reason of my illiteracy, illness or physical disability, I have made or have received assistance in making my mark in lieu
of my signature.
Date Name of Voter Mark
I, the undersigned, hereby certify that the above named voter affixed his mark to this application in my presence and I know him to be the
person who affixed his mark to said application and understand that this statement will be accepted for all purposes as the equivalent of an
affidavit and if it contains a material false statement, shall subject me to the same penalties as if I had been duly sworn.
(Address of witness to mark) (Signature of witness to mark)
