Fillable AUTHORIZE A DESIGNATED AGENT TO HELP YOU OBTAIN (Monroe County)

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AUTHORIZE A DESIGNATED AGENT TO HELP YOU OBTAIN (Monroe County)

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AUTHORIZE A DESIGNATED AGENT TO HELP
YOU OBTAIN AND/OR RETURN YOUR MAIL-IN
OR ABSENTEE BALLOT
DOS-10/2020
Who can use this form?
You can use this form if you have a disability, as dened by the Americans with Disabilities Act, and it prevents
you from doing any of the following:
• Submitting a paper application for a mail-in or absentee ballot.
• Obtaining your mail-in or absentee ballot in person.
• Returning your voted mail-in or absentee ballot.
What can I do with this form?
Use this form to authorize a designated agent to submit a paper application for, obtain, and/or return your mail-
in or absentee ballot on your behalf. Visit VotesPA.com/mailballot or call 1-877-868-3772 for more information.
Who can be a designated agent?
The person you designate as your agent is only allowed to serve as a designated agent for ONE voter, unless
the additional voter(s) live in the same household as you (the voter named in this form).
How do I use this form?
If you have not yet requested your ballot:
• You and the designated agent must complete page 2 of this form.
• The DESIGNATED AGENT SHOULD RETAIN A COPY of the form - they may need to have it
on hand when delivering your balloting materials.
• Return this completed Authorize a Designated Agent Form along with your completed mail-in or absentee
ballot application to the county board of elections in person.
• If you mail the Authorize a Designated Agent form to the county board of elections with your completed
mail-in or absentee ballot application, the county will mail the balloting materials to the address provided on
the mail-in or absentee application.
• Then, either you or your designated agent may return your voted ballot to the board of elections by mail or
in-person.
If you have already requested your ballot:
• You and the designated agent must complete page 2 of this form.
• The DESIGNATED AGENT SHOULD RETAIN A COPY of the form and keep it on hand when
delivering your balloting materials.
• Contact your county election ofce for information about how and where to return the completed Authorize
a Designated Agent form.
• DO NOT insert the Authorize a Designated Agent form in the white inner secrecy envelope that contains
your voted ballot.
AUTHORIZE A DESIGNATED AGENT TO HELP
YOU OBTAIN AND/OR RETURN YOUR MAIL-IN
OR ABSENTEE BALLOT
DOS-10/2020
DateSignature of Voter
To be
Completed
by the
Voter:
Jr Sr ll lll lV
Middle name or initial:
*Address Line 1:
Address Line 2:
*First name: *Last name:
*County
*City/Town *State *Zip Code
I afrm that I am a voter with a disability as dened in the Americans with Disabilities Act.
As such, I hereby authorize ____________________________________________________________________
(name of designated agent) to do any or all of the following on my behalf: submit a completed paper
ballot application to my County Board of Elections, pick up a ballot for me to complete, and deliver
or mail the completed ballot to my County Board of Elections. I afrm that I am an eligible voter in the
above County and that my signature and name are as shown on this form.
If returning with voted ballot:
I afrm that I have not attempted and will not attempt to submit more than one ballot in this election,
and that my ballot has been or will be delivered in accordance with the applicable provisions of the
Pennsylvania Election Code.
I make this unsworn statement with the knowledge that any false statement made herein is
punishable under 18 Pa.C.S. § 4904 relating to unsworn falsication to authorities.
DateSignature of Designated Agent
To be
Completed
by the
Designated
Agent:
Jr Sr ll lll lV
Middle name or initial:
*Address Line 1:
Address Line 2:
*First name: *Last name:
*County
*City/Town *State *Zip Code
I agree to serve as the designated agent for _____________________________________________________
(printed name of voter), who requires assistance because of a disability as dened under the Americans
with Disabilities Act, and who authorized me to do any or all of the following on his or her behalf: submit
a completed ballot application to the County Board of Elections, pick up a ballot for the above-named
voter to complete, and deliver or mail the completed ballot to the Board of Elections after the ballot has
been completed in accord with the applicable provisions of the Pennsylvania Election Code. I certify
that I have not altered or marked the application, ballot, or return envelope in any manner. Furthermore,
I certify that I am not acting as a designated agent during this election for any person who does not live
in the same household as the above-named voter. I make this unsworn statement with the knowledge
that any false statement made herein is punishable under 18 Pa.C.S. § 4904 relating to unsworn
falsication to authorities.
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AUTHORIZE A DESIGNATED AGENT TO HELP YOU OBTAIN (Monroe County)

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Completed 25 January 2021

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