IV. Applicant’s Name (Please Print):
__________________________________________________________________________
Last Name First Name Middle Name (Jr., Sr., II,III)
Applicant’s Voting Domicile (home address):
__________________________________________________________________________
Street Number Street Name Apt/Unit City/Town Ward Zip Code
Mail the ballot to me at this address (if different than the home address)
__________________________________________________________________________
Street or PO Box # Street name Apt/Unit City/Town State Zip Code
Applicant’s Phone Number: (_____) ______ - _____________
(Cell phone or number where you can be contacted prior to and on election day is preferred)
Applicant’s Email Address: ______________________@__________
Applicant’s Signature: _____________________________Date Signed: _______________
The applicant must sign this form to receive an absentee ballot. Any person who witnesses and
assists a voter with a disability in executing this form shall print and sign his or her name in the
space provided on the application form. The moderator will not compare the voter’s signature on
the application with the signature on the absentee ballot affidavit when a person assisting the
voter has signed the statement on the absentee ballot application or affidavit envelope that
assistance was provided. (Enforcement of the struckthrough provision has been enjoined. See Saucedo v. Gardner,
335 F. Supp. 3d 202 (D.N.H. 2018)
I attest that I assisted the applicant in executing this form because he or she has a disability.
Signature ________________________Print Name ________________________________
If your absentee ballot application or affidavit envelope has the printed name and signature of a
person who assisted you with voting, your signature will not be compared to your signature on the
absentee ballot affidavit to verify your identity. Otherwise, if your signatures do not appear to be
made by the same person, your absentee ballot may not be counted. (Enforcement of the struckthrough
provision has been enjoined. See Saucedo v. Gardner, 335 F. Supp. 3d 202 (D.N.H. 2018)
Mail/fax/ or hand deliver this completed form to your local City/Town Clerk.
For local clerk addresses and fax numbers: https://app.sos.nh.gov
– Click on “Clerk Information Search”
tab.
Visit the web site: https://app.sos.nh.gov/Public/AbsenteeBallot.aspx to track your absentee ballot. You may
verify receipt of your application, obtain the date when your absentee ballot was mailed to you, the date the
clerk receives your completed absentee ballot, and after the election learn if your absentee ballot was
rejected/not counted and why. Contact your clerk if you have questions regarding the information on the
“Voter Information Look-up / Absentee Ballot Search” site.
For Official Use Only:
Voter Verified
