_________________________ COUNTY or MUNICIPALITY GA Driver’s License # ____________________
APPLICATION FOR OFFICIAL ABSENTEE BALLOT
PLEASE PRINT (FAILURE TO FILL OUT THE FORM COMPLETELY COULD DELAY YOUR APPLICATION)
Date of Primary, Election, or Runoff: _____/_____/20____
FOR PRIMARY ELECTIONS ONLY (please check one): DEMOCRATIC NON PARTISAN REPUBLICAN
DATE OF BIRTH
EMAIL ADDRESS(required for UOCAVA
Voter requesting electronic transmission)
NAME AS REGISTERED LAST FIRST MIDDLE
ADDRESS AS REGISTERED STREET # CITY ZIP CODE
Mail the ballot to my temporary out-of-county address: (or alternate address for physically disabled voter).
# STREET CITY STATE ZIP CODE
Note: You must file a separate application for each election for which you are requesting an absentee ballot (*see
exceptions below for voters over the age of 65, disabled, or military or overseas citizens). You may file your application no
more than 180 days prior to the Date of the Election.
If you meet the following criteria, you may choose to complete one application and receive a ballot for the General Primary,
General Primary Runoff (if any), General Election, and General Election Runoff (if any) by checking one of the following boxes:
E - Elderly - I am 65 years of age or older.
D - Disabled - I have a physical disability.
U – UOCAVA Voter - Member of armed forces or Merchant Marines of the United States, commissioned corps of the Public
Health Service or the National Oceanic and Atmospheric Administration, spouse or dependent residing with or accompanying said
member, or a United States citizen residing overseas. My current status is (please mark one):
MOS – Military Overseas MST – Military Stateside
OST – Overseas Temporary Resident OSP – Overseas Permanent Resident (federal offices only)
For UOCAVA Voters Only - I would like to receive my absentee ballots by electronic transmission .
SIGNATURE OR MARK* OF VOTER - REQUIRED *Signature of person preparing application if voter is disabled or illiterate - REQUIRED
You may apply on behalf of another person only in the following circumstances: In the case of a voter residing temporarily out of the county or a physically
disabled voter residing within the county, application may be made by mother, father, grandparent, brother, sister, aunt, uncle, spouse, son, daughter, niece,
nephew, grandchild, son-in-law, daughter-in-law, mother-in-law, father-in-law, brother-in-law or sister-in-law of the age of 18 or over upon completing the following
oath: I, the undersigned do swear (or affirm) that the above-named voter is (check one): residing temporarily out of the county or is a physically disabled
voter residing within the county and that the facts included in this application are true.
SIGNATURE AND RELATIONSHIP OF RELATIVE REQUESTING BALLOT - REQUIRED
OFFICE USE ONLY
Voter Registration #_________________________
DIST. COMBO PRECINCT I HEREBY CERTIFY THAT THE ABOVE NAMED VOTER PACKET PREPARED BY:
IS ELIGIBLE ______________
APPLICATION RECEIVED DATE ____________
BALLOT # __________ ISS. DATE ___________
IS NOT ELIGIBLE TO RECEIVE AN ABSENTEE BALLOT PACKET REVIEWED BY:
CERTIFIED DATE __________ REJECTION DATE__________
ID SHOWN: GADL OTHER _________________________ REASON FOR REJECTION: __________________________ _______________
Ballot to be: Mailed Electronically Transmitted
Delivered to voter in hospital by Registrar/Deputy Registrar
Voted in office (Municipal Only) Registrar Signature ___________________________________