This application may be completed by...
• A registered voter; or
• A voter’s family member (spouse, roommate, parent, sibling, child, aunt, uncle, niece, nephew,
grandparent, grandchild, in-law).
Use this application to request an absentee ballot for...
A registered voter who will be unable to vote at the polls on Election Day due to absence from
the voter’s city or town during polling hours, disability, or religious beliefs.
A non-registered voter who is:
• A Massachusetts citizen absent from the state;
• An active member of the armed forces or merchant marines, their spouse or dependent; or
• A person conned to a correctional facility or jail for reasons other than felony conviction.
Completing the Application
1. Voter Information – Provide the voter’s name, legal voting address, and date of birth.
Telephone number and e-mail address are optional elds
2. Ballot Information – Provide the address where you want the ballot mailed and indicate for
which election(s) you are requesting a ballot. For primaries, if the voter is not enrolled in a
party, provide the desired party ballot. Applications for “all elections this year” are valid for one
3. Special Circumstances – Check any of the listed circumstances which apply
to this application, if any.
4. Sign your name. If you require assistance in signing the application, you may authorize
someone to sign your name in your presence. That person must complete the assisting
person’s information in Section 3.
Submitting the Application
Send the completed application to the local election ofcial at the voter’s city or town hall.
Applications can be mailed or hand-delivered. Applications may also be submitted electronically
by fax or e-mail, as long as the requester’s signature is visible.
Find contact information for local election ofcials at www.sec.state.ma.us/ele or by
calling 1-800-462-VOTE (8683).
FOR REGISTRAR USE ONLY
We certify that the voter for whom this application is being made appears to be eligible to vote from the
address listed on the application.