MI Absent Voter Ballot Application – May 3, 2016 Election
I am a United States citizen and a qualified and registered elector of the County and jurisdiction in the State of Michigan listed below, and
I apply for an official ballot, to be voted by me at the above indicated election.
Applicant Registration Information:
First Name M.I. Last Name
The reason for my request is (required):
I am 60 years of age or older.
I expect to be absent from the community in which I am registered for the entire time the polls are open on election day.
I am physically unable to attend the polls without the assistance of another.
I cannot attend the polls because of the tenets of my religion.
I have been appointed an election precinct inspector in a precinct other than the precinct where I reside.
I cannot attend the polls because I am confined to jail awaiting arraignment or trial.
I certify that I am a United States citizen and that the statements in this absent voter ballot application are true.
X / /
WARNING: You must be a United States citizen to vote. If you are not a United States citizen, you will not be issued an absent voter ballot. A person making a
false statement in this absent voter ballot application is guilty of a misdemeanor. It is a violation of Michigan election law for a person other than those listed in the
instructions to return, offer to return, agree to return, or solicit to return your absent voter ballot application to the clerk. An assistant authorized by the clerk who
receives absent voter ballot applications at a location other than the clerk’s office must have credentials signed by the clerk. Ask to see his or her credentials before
entrusting your application with a person claiming to have the clerk’s authorization to return your application.
Return this application to your local clerk. Find your clerk at mi.gov/vote.
Additional Information:
Complete only if you want your ballot sent to a temporary address:
Contact Info for Questions
temporary address:
/ /
Date of return:
NOTE: Absentee ballots will not be forwarded by USPS.
Complete only
if assisting a
voter with
return of the
application
Certificate of Authorized Registered Elector Returning Absent Voter Ballot Application:
I certify that my name is ____________________________________________, date of birth is
____/____/____ and my address is _________________________________________________________;
that I am delivering the absent voter ballot application of _________________________________________
at his or her request; that I did not solicit or request to return the application; that I have not made any
markings on the application; that I have not altered the application in any way; that I have not influenced the
applicant; and that I am aware that a false statement in this certificate is a violation of Michigan election law.
X_______________________________________ ____/____/____
Signature of person assisting the voter Date
S E E P A G E 2 F O R F U R T H E R I N S T R U C T I O N S
