REQUEST FOR EARLY ABSENTEE VOTER BALLOT (VALID for ONE CALENDAR YEAR)
(All voters must submit a new request for absentee ballots each year.)
(SUBMIT DIRECTLY to the Town Clerk of the town in which you are on the voter checklist.)
Former Name
(if applicable) _____________________________________________________________
Other Contact Info
If applicable
Legal Address
where you are
Registered to Vote
2 Phone Number_______________________ Email___________________________________
Street Address
(no P.O. boxes)
State
Required must be your
town of Residence
Mailing Address
Required only if you wish to
have your ballot mailed to a
different address than the
address at which you're
registered to vote.
Election
Required
City ZIP
Street Address (or P.O. box)
City
State
ZIP
Date Range Request:_______________ to _______________(within a calendar year)
MM/ DD/ YYYY MM/ DD/ YYYY
Annual Town Meeting All Local Elections
Presidential Primary Election (
You Must Select a Party) Democratic Ballot Republican Ballot
General Election Primary Election
Military, Civilian
Overseas, Ill or
with Disability
Voters
If Applicable
Check one: Military Overseas voter (Active in U.S. or overseas) Ill or with Disability
Please deliver the ballots(s) and all election materials as indicated below (check one):
Email Address:___________________________________________________(Ballots cannot be returned electronically)
Fax Number:_________________________________________________
Mail: __________________________________________________________________________________________
Deliver by two Justices of the Peace
(This can only be selected if you are ill or physically disabled.) Phone number: _______________
Signature
__________________________________ Date:___________________
Signature of Voter or Authorized Person
IF YOU ARE REQUESTING A BALLOT FOR SOMEONE OTHER THAN YOURSELF, you must complete the information below:
Relationship to Voter: Family member Health care provider Person authorized by voter
Name of Requestor: _________________________________ Signature
(Required): __________________________________ Date:___________________
Organization Name
(if applicable):__________________________________________________________ Phone number:____________________________
Address of Requestor:_________________________________________________________________________________________________________
For Clerk Use Only: Voted in Office Date of Request: ______________________
Ballot picked up at clerk’s office Ballot Mailed Date: ____________________
Ballot Returned Date: __________________
Voter Name
Required
1
First
Middle
Last
Suffix
3
4
5
6
7
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