APPLICATION FOR ABSENTEE BALLOT
Pursuant to Senate Bill 1202 of the June Special Session 2021, COVID-19 may be used as
a valid reason for requesting a ballot for any Primary, Election or Referendum held
before November 3, 2021.
Sect
ion I. – Applicant’s Information
Name: Date of Birth
Home Address: Zip Code
(Number, Street, Town)
Telephone No. E-mail Address______________________________
Mailing Address:
(Use only if the mailing address is different from the address above.)
Section II. – Statement of Applicant - Required
I, the undersigned applicant, believe that I am eligible to vote at the Primary, Election or
Referendum held in my municipality. I expect to be unable to appear at the polling place during the hours of voting and hereby apply
for an absentee ballot: (you MUST check one)
□ COVID-19 ► All voters are able to check this box, pursuant to Senate Bill 1202 of the June Special Session 2021◄
□ My active service in the Armed Forces of the United States
□ My absence from the town during all of the hours of voting
□ My illness
□ My religious tenets forbid secular activity on the day of the election, primary or referendum
□ My duties as a primary, election or referendum official at a polling place other than my own during all of the hours of
voting
□ My physical disability
**For
Referendum (Date________________________) **For Primary (Date_______________ / Party________________)
Fo
r Military/Overseas Personnel only, please indicate if you would like your absentee ballot sent to you electronically to the email
address provided above (Yes__ No __)
Sect
ion III. – Applicant’s Declaration - Required
I declare, under the penalties of false statement in absentee balloting, that the above statements are true and correct, and that I am the
applicant named above.
(Sign your legal name in full. If you are unable to write, you may authorize some one to write your name and the date in the spaces
provided, followed by the word “by” and the signature of the authorized person. Such person must also complete section IV below.)
Signature of Applicant: Date Signed:
Section IV. – Declaration of person providing assistance
(Completed by any person who assists with completion of application)
I sign this application under penalties of false statement in absentee balloting.
Signature: Printed Name: Tel. No:
Residence Address:
SPECIAL INSTRUCTIONS
Connecticut law allows you to receive an absentee ballot if you cannot appear at your assigned polling place on election day
because of active service in the Military, absence from the town during all of the hours of voting, illness, religious tenets forbid
secular activity on the day of the election, duties as an election official at a polling place other than your own during all of the
hours of voting, or physical disability. The State of Connecticut, via Senate Bill 1202 of the June Special Session 2021, has
determined that the existence of the COVID-19 virus allows you to vote by absentee ballot if you so choose for your own safety. To
receive your absentee ballot please complete and sign this application and return it to your Town Clerk.
Fo
r Municipal Clerk’s Use
Outer Envelope Serial No.
►
Applicant
Applicant
Personally
