Ofce of the Kansas Secretary of State
Application for Advance Ballot by Mail
DOWNLOAD THIS FORM AT WWW.SOS.KS.GOV
1. Afrmation
Afrmation of an Elector of the County of ____________________ and State of Kansas Desiring to Vote an Advance Voting Ballot
State of ____________________, County of ____________________, ss: (where application is completed)
2. Voter Identication Requirements
I understand that my current and valid Kansas driver’s license number or Kansas nondriver’s identication card number
must be provided in order to receive a ballot.
Current Kansas driver’s license number or nondriver’s identication card number: ________________________________
If I do not have a current and valid Kansas driver’s license number or Kansas nondriver’s identication card number, I
must provide a copy of one of the following forms of photo identication with this application in order to receive a ballot.
3. Personal Information Please print.
______________________________ ______________________________ ____ __________________________
Last Name First Name M.I. Date of Birth (MM/DD/YY)
__________________________________________ _______________________ __________ _____________
Residential Address City State Zip Code
Political Party (To be lled in only when requesting a primary election ballot): □ Democratic □ Republican
4. Address to Mail Ballot (if different from residential address)
__________________________________________ _______________________ __________ _____________
Mailing Address City State Zip Code
Note: The ballot may be mailed only to the voter’s residential or mailing address as indicated on the county voter registration list, to the voter’s
temporary residential address, or to a medical care facility where the voter resides. These restrictions do not apply to a voter who has an illness,
disability or who lacks prociency in the English language. Ballots cannot be mailed until 20 days before the election.
5. Voter Signature Note: False statement on this afrmation is a severity level 9, nonperson felony.
I do solemnly afrm under penalty of perjury that I am a qualied elector residing at the address listed above, or I am
authorized to sign for the above named voter who has a disability preventing the voter from signing an application. I am
entitled to vote an advance voting ballot and I have not voted and will not otherwise vote at the election to be held on
____________________ (date).
______________________________ _________________________ ________________________
Signature of Voter Date (MM/DD/YY) Phone Number
Prepared by the Ofce of the Secretary of State, 1st Floor, Memorial Hall, 120 S.W. 10th Avenue, Topeka, KS 66612-1594.
KSA 25-1122d(a). Rev 9/24/19 tc
FOR OFFICE USE ONLY Date App. Rec’d. ____________ Ballot Mailed ____________ Transmitted by ____________
FORM
AV1M
• Driver’s license issued by Kansas or another state
• Nondriver’s ID card issued by Kansas or another state
• U.S. passport
• Concealed carry of handgun license issued by Kansas
or another state
• Employee badge or ID document issued by a government ofce
• U.S. military ID
• Student ID card issued by an accredited Kansas postsecondary
educational institution
• Public assistance ID card issued by a government ofce
• ID card issued by an Indian tribe
Required
Please complete the form, sign and send
to the Kansas Secretary of State.
Selecting "Print" will print the form and
"Reset" will reset the entire form.
