COUNTY or MUNICIPALITY
APPLICATION FOR OFFICIAL ABSENTEE BALLOT
PLEASE PRINT (FAILURE TO FILL OUT THE FORM COMPLETELY COULD DELAY YOUR APPLICATION)
Date of Primary, Election, or Runoff:
FOR PRIMARY ELECTIONS ONLY (please check one): DEMOCRATIC NON PARTISAN REPUBLICAN
APPLICATION
DATE
_/_ _/_
_
DAYTIME
CONTACT
NUMBER
(optional)
( ) -
___
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
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.
IS
ELIGIBLE
APPLICATION
RECEIVED
DATE
BALLOT
#
ISS.
DATE
CERTIFIED
DATE
REJECTION
DATE
ID SHOW N: 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
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
more than 180 days prior to the Date of the Election.
*EXCEPTIONS:
If you meet the following criteria, you may choose to complete one application and receive a ballot for the General Primary,
SIGNATURE AND RELATIONSHIP OF RELATIVE REQUESTING BALLOT - REQUIRED
OFFICE USE ONLY
FORM #ABS-APP-18
Voter
Registration
#
DIST. COMBO PRECINCT I HEREBY CERTIFY THAT THE ABOVE NAMED VOTER PACKET PREPARED BY:
IS NOT ELIGIBLE TO RECEIVE AN ABSENTEE BALLOT PACKET REVIEWED BY:
/ _/20 _
click to sign
signature
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