Fillable ApplicationForAbsenteeBallot - 42106

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ApplicationForAbsenteeBallot - 42106

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APPLICATION FOR ABSENTEE BALLOT For Election on _______/________/_________ (ABS-1)
State Form 42106 (R20 / 6-12) Indiana Election Commission (IC 3-11-4-2; 3-11-4-5.1; 3-11-10-24)
FOR COUNTY ELECTION BOARD USE ONLY
Precinct ADDITIONAL
DOCUMENTATION
Is applicant required to provide additional identification documentation to the
county voter registration office but has not yet done so? Yes No
INSTRUCTIONS: The voter (or the voter’s power of attorney) must SIGN the application below. If you are applying as the voter’s attorney in fact, a copy of the power of attorney must be attached.
Complete and return this application to your county election board, so that the application is received at least 8 days before the election. You can return this application by FAX. NOTE: Certain voters who
registered by mail are required to provide additional personal identification before voting an absentee ballot. Contact your county voter registration office for information if you think this may
apply to you. Note: If you are an overseas voter or uniformed services (military) voter, use form ABS-15.
Return by mail to this county address: _________________________________________Telephone (________)______________ Fax (________)_______________
1. INFORMATION OF ABSENTEE BALLOT APPLICANT
Name (please print) Date of Birth (mm/dd/yy)
______/______/______
Last Four Digits of Social Security Number: __ __ __ __
NOTE: Voter’s Compliance with this request is OPTIONAL.
I do not have a Social Security Number.
Registration Address
(
number and
street)
City/Town, State, ZIP
Code
Telephone Number (Day)
( )
Telephone Number (Evening)
( )
2. MAILING ADDRESS OF ABSENTEE BALLOT APPLICANT (If different from registration address)
Mailing Address
(
number and
street)
City/Town, State, ZIP
Code
3. COMPLETE THIS SECTION OF APPLICATION FOR PRIMARY ELECTION ONLY
In Indiana, you must request a major political party ballot to vote in the primary election.
However, you may vote on a public question without voting a political party ballot, if a referendum is held at the same time as the primary.
I apply for the ballots of the (check one box) Democratic Party OR Republican Party, a majority of whose candidates I expect to vote for in the general or
municipal election; OR
Public Question Only
4. ABSENTEE VOTING METHOD (Choose A, B or C)
A. Voting by Mail (Application due by 11:59 p.m., _____/_____/_____ )
Check one:
I have a specific, reasonable expectation of being absent from the county on election
day during the entire 12 hours that the polls are open.
I am a voter with disabilities. If you are unable to mark the ballot or sign the envelope,
you must vote before a traveling board or in the Clerk’s office. Go to Box B or C.
I am a voter at least 65 years of age.
I will have official election duties outside of my voting precinct.
I am a voter eligible to vote under the “fail-safe” procedures in IC 3-10-11 or 3-10-12.
I am scheduled to work at my regular place of employment during the entire 12 hours that
the polls are open.
I will be confined to my residence, a health care facility, or a hospital due to illness or injury
during the entire 12 hours that the polls are open.
I will be caring for an individual confined to a private residence due to illness or injury during
the entire 12 hours that the polls are open.
I am unable to vote at the polls in person due to observance of a religious discipline or
religious holiday during the entire 12 hours the polls are open.
I am an address confidentiality program participant in the program administered by
the Indiana Attorney General under IC 5-26.5-1-6.
I am a member of the military or public safety officer.
B. Voting in the Clerk’s Office (in Lake and Tippecanoe Counties, the Election Board Office) (Voting closes _______/_________/________, at noon)
C. Voting by Traveling Board (Application due by _____/______/______ at noon if hand delivered;
by _______/_______/______ at noon if mailed or faxed)
I expect to be confined, due to illness or injury, or I expect to be caring for a confined person at a private
residence, on election day.
I am a voter with disabilities and believe my polling place is not accessible to me.
VOTE ME AT THE FOLLOWING ADDRESS:
____________________________________________
____________________________________________
I request that the county election board
authorize the
traveling board to visit me outside the county at the
place listed above.
Approved Denied
I swear or affirm under the penalties of perjury that all of the information set forth on this application is true to the best of my knowledge and belief.
Signature of voter (or person designated by a county election board to sign for a voter with disabilities)
X
Date signed (month, day, year)
________/___________/____________
5. INFORMATION OF INDIVIDUAL ASSISTING ABSENTEE BALLOT APPLICANT
Name (please print)
Date Assistance to Applicant Provided
________/___________/____________
Residence Address (number and street)
City/Town, State, ZIP
Code
Telephone Number (Day)
( )
Mailing Address
(
number and
street) (If different from
residence
address)
City/Town, State, ZIP
Code
Telephone Number (Evening)
( )
I swear or affirm under the penalties of perjury that I have no knowledge or reason to believe that the individual submitting the application:
(1) is ineligible to vote or to cast an absentee ballot; or (2) did not properly complete and sign the application.
Signature of Person Assisting Voter with Application Date signed (month, day, year)
________/___________/____________
Penalty for Perjury: A person who makes a false, material statement under oath or affirmation, knowing the statement to be false or not believing it to be
true commits perjury, a Class D felony, which is punishable by imprisonment for up to 3 years, a fine of up to $10,000 or both.
Reset Form
Indiana County Offices
Complete and sign this absentee ballot application and mail it to the county where you are registered to vote or to the Indiana Election Division.
ADAMS
Adams Co. Circuit Court Clerk
P.O. Box 189
Decatur, IN 46733 – 0189
(260) 724-5309
ALLEN
Allen Co. Circuit Court Clerk
1 West Superior Street
Fort Wayne, IN 46802 -1213
(260) 449-7329
BARTHOLOMEW
Bartholomew Co. Circuit Court Clerk
P.O. Box 924
Columbus, IN 47202 - 0924
(812) 379-1600
BENTON
Benton Co. Circuit Court Clerk
706 E. 5
th
Street
Suite 37
Fowler, IN 47944 - 1556
(765) 884-0930
BLACKFORD
Blackford Co. Circuit Court Clerk
110 W. Washington St.
Hartford City, IN 47348 - 2298
(765) 348-1130
BOONE
Boone Co. Circuit Court Clerk
Room 212, Courthouse Square
Lebanon, IN 46052 - 2100
(765) 482-3510
BROWN
Brown Co. Circuit Court Clerk
P.O. Box 85
Nashville, IN 47448 - 0085
(812) 988-5510
CARROLL
Carroll Co. Circuit Court Clerk
101 W. Main St.
Delphi, IN 46923
(765) 564-4485
CASS
Cass Co. Circuit Court Clerk
200 Court Park, Room 103
Logansport, IN 46947-3192
(574) 753-7740
CLARK
Clark Co. Circuit Court Clerk
501 E. Court Avenue, Room 131
Jeffersonville, IN 47130 - 4090
(812) 285-6329
CLAY
Clay Co. Circuit Court Clerk
609 E. National Ave., Rm 213
Brazil, IN 47834
(812) 448-9024
CLINTON
Clinton Co. Circuit Court Clerk
265 Courthouse Square
Frankfort, IN 46041 - 1993
(765) 659-6335
CRAWFORD
Crawford Co. Circuit Court Clerk
P.O. Box 375
316 Court St.
English, IN 47118 - 0375
(812) 338-2565
DAVIESS
Daviess Co. Circuit Court Clerk
200 E. Walnut Street
P.O. Box 739
Washington, IN 47501 - 0739
(812) 254-8679
DEARBORN
Dearborn Co. Circuit Court Clerk
215 W. High Street
Lawrenceburg, IN 47025 - 1909
(812) 537-8867
DECATUR
Decatur Co. Circuit Court Clerk
150 Courthouse Square
Suite 244
Greensburg, IN 47240 - 2080
(812) 663-8223
DEKALB
Dekalb Co. Circuit Court Clerk
P.O. Box 230
100 S. Main Street
Auburn, IN 46706 - 0230
(260) 925-9787
DELAWARE
Delaware Co. Circuit Court Clerk
100 West Main Street
Muncie, IN 47305
(765) 747- 7726
DUBOIS
Dubois Co. Circuit Court Clerk
One Courthouse Square, Room 104
Jasper, IN 47546 - 3058
(812) 481-7037
ELKHART
Elkhart Co. Circuit Court Clerk
101 North Main Street, Rm 204
Goshen, IN 46526
(574) 535-6430
FAYETTE
Fayette Co. Circuit Court Clerk
401 Central Ave
Connersville, IN 47331
(765) 825-1813
FLOYD
Floyd Co. Circuit Court Clerk
311 Hauss Square, Rm. 235
New Albany, IN 47150-3584
(812) 948-5415
FOUNTAIN
Fountain Co. Circuit Court Clerk
P.O. Box 183
Covington, IN 47932
(765) 793-2192
FRANKLIN
Franklin Co. Circuit Court Clerk
459 Main Street
Brookville, IN 47012 - 1486
(765) 647-5111
FULTON
Fulton Co. Circuit Court Clerk
815 Main Street
Rochester, IN 46975
(574) 223-4824
GIBSON
Gibson Co. Circuit Court Clerk
P.O. Box 630
Princeton, IN 47670 - 0630
(812) 385-2541
GRANT
Grant Co. Circuit Court Clerk
Courthouse
101 E. 4
th
Street
Marion, IN 46952
(765) 668-8121
GREENE
Greene Co. Circuit Court Clerk
P.O. Box 229
Bloomfield, IN 47424 - 0229
(812) 384-8532
HAMILTON
Hamilton Co. Circuit Court Clerk
1 Hamilton County Square
Suite 106
Noblesville, IN 46060 - 2230
(317) 776-8476
HANCOCK
Hancock Co. Circuit Court Clerk
9 East Main Street
Room 213
Greenfield, IN 46140
(317) 477-1109
HARRISON
Harrison Co. Circuit Court Clerk
Courthouse, Room 203
300 North Capitol Avenue
Corydon, IN 47112 - 1155
(812) 738-4289
HENDRICKS
Hendricks Co. Circuit Court Clerk
355 S Washington St, STE 218
Danville, IN 46122 - 1798
(317) 745-9231
HENRY
Henry Co. Circuit Court Clerk
P.O. Box B
New Castle, IN 47362 - 1044
(765) 529-9310
HOWARD
Howard Co. Circuit Court Clerk
104 North Buckeye Street, Room 114
Kokomo, IN 46901
(765) 456-2204
HUNTINGTON
Huntington Co. Circuit Court Clerk
P.O. Box 228
201 North Jefferson Street, Rm 201
Huntington, IN 46750
(260) 358-4819
JACKSON
Jackson Co. Circuit Court Clerk
111 South Main Street
P.O. Box 318
Brownstown, IN 47220 - 0318
(812) 358-6117
JASPER
Jasper Co. Circuit Court Clerk
115 West Washington St., Suite 204
Rensselaer, IN 47978
(219) 866-4927
JAY
Jay Co. Circuit Court Clerk
120 Court Street
Portland, IN 47371 – 2195
(260) 726-6915
JEFFERSON
Jefferson Co. Circuit Court Clerk
Courthouse, Room 203
300 East Main Street
Madison, IN 47250 - 3594
(812) 265-8924
JENNINGS
Jennings Co. Circuit Court Clerk
P.O. Box 385
Vernon, IN 47282 - 0385
(812) 352-3070
JOHNSON
Johnson Co. Circuit Court Clerk
P.O. Box 451
Franklin, IN 46131 - 0451
(317) 346-4450
KNOX
Knox Co. Circuit Court Clerk
111 North 7
th
Street, Ste 28
Vincennes, IN 47591 - 2022
(812) 885-2521
KOSCIUSKO
Kosciusko Co. Circuit Court Clerk
121 North Lake Street
Warsaw, IN 46580 - 2788
(574) 372-2334
LAGRANGE
LaGrange Co. Circuit Court Clerk
105 North Detroit Street
LaGrange, IN 46761 - 1801
(260) 499-6368
LAKE
Lake Co. Board of Voter Registration
2293 North Main Street, Suite 16
Crown Point, IN 46307
(219) 755-3533
LAPORTE
LaPorte Co. Circuit Court Clerk
813 Lincolnway, Suite 105
LaPorte, IN 46350 - 3492
(219) 326-6808 ext. 2465
LAWRENCE
Lawrence Co. Circuit Court Clerk
916 15
th
St. Room 31
Bedford, IN 47421 - 3800
(812) 275-4145
MADISON
Madison Co. Circuit Court Clerk
16 East 9
th
Street, Suite 213
Anderson, IN 46016
(765) 641-9457
MARION
Marion Co. Circuit Court Clerk
200 East Washington, W122
Indianapolis, IN 46204
(317) 327-5100
MARSHALL
Marshall Co. Circuit Court Clerk
211 West Madison Street
Plymouth, IN 46563 - 1762
(574) 935-8713
MARTIN
Martin Co. Circuit Court Clerk
111 Main St.
P.O. Box 120
Shoals, IN 47581
(812) 247-3651
MIAMI
Miami Co. Circuit Court Clerk
P.O. Box 184
Peru, IN 46970 - 0184
(765) 472-3901 ext. 256
MONROE
Monroe Co. Circuit Court Clerk
P.O. Box 547
Bloomington, IN 47402
(812) 349-2614
MONTGOMERY
Montgomery Co. Circuit Court Clerk
P.O. Box 768
Crawfordsville, IN 47933 - 0768
(765) 364-6434
MORGAN
Morgan Co. Circuit Court Clerk
180 S Main St, Ste 1
Martinsville, IN 46151
(765) 342-1029
NEWTON
Newton Co. Circuit Court Clerk
P.O. Box 49
Kentland, IN 47951 - 0049
(219) 474-6081
NOBLE
Noble Co. Circuit Court Clerk
101 North Orange Street
Albion, IN 46701 – 1092
(260) 636-2736, ext 430
OHIO
Ohio Co. Circuit Court Clerk
P.O. Box 185
Rising Sun, IN 47040 - 0185
(812) 438-2610
ORANGE
Orange Co. Circuit Court Clerk
1 Court Street
Orange County Courthouse
Paoli, IN 47454 - 9632
(812) 723-2649
OWEN
Owen Co. Circuit Court Clerk
P.O. Box 146
Spencer, IN 47460 - 0146
(812) 829-5028
PARKE
Parke Co. Circuit Court Clerk
116 West High Street
Room 204
Rockville, IN 47872 - 1781
(765) 569-5132
PERRY
Perry Co. Circuit Court Clerk
2219 Payne Street
Tell City, IN 47586 - 2832
(812) 547-3741
PIKE
Pike Co. Circuit Court Clerk
P.O. Box 125
Petersburg, IN 47567
(812) 354-6025
PORTER
Porter Co. Circuit Court Clerk
16 E. Lincolnway, Rm 209
Valparaiso, IN 46383
(219) 465-3450, ext 463
POSEY
Posey Co. Circuit Court Clerk
P.O. Box 606
Mt. Vernon, IN 47620 - 0606
(812) 838-1306
PULASKI
Pulaski Co. Circuit Court Clerk
112 East Main
Room 230
Winamac, IN 46966 - 1394
(574) 946-3313
PUTNAM
Putnam Co. Circuit Court Clerk
P.O. Box 546
Greencastle, IN 46135 - 0546
(765) 653-2648
RANDOLPH
Randolph Co. Circuit Court Clerk
P.O. Box 230
Winchester, IN 47394 - 0230
(765) 584-4214
RIPLEY
Ripley Co. Circuit Court Clerk
P.O. Box 177
115 N. Main Street
Versailles, IN 47042
(812) 689-6115
RUSH
Rush Co. Circuit Court Clerk
101 East 2
nd
Street, Room 209
Rushville, IN 46173
(765) 932-2086
ST. JOSEPH
St. Joseph Co. Circuit Court Clerk
101 South Main Street
South Bend, IN 46601
(574) 235-9635
SCOTT
Scott Co. Circuit Court Clerk
1 East McClain Avenue, Suite 120
Scottsburg, IN 47170 - 1885
(812) 752-8420
SHELBY
Shelby Co. Circuit Court Clerk
407 S. Harrison St., Ste 111
Shelbyville, IN 46176
(317) 392-6320
SPENCER
Spencer Co. Circuit Court Clerk
P.O. Box 12
200 Main Street
Rockport, IN 47635 - 0012
(812) 649-6029
STARKE
Starke Co. Circuit Court Clerk
P.O. Box 395
Knox, IN 46534
(574) 772-9128
STEUBEN
Steuben Co. Circuit Court Clerk
55 South Public Square
Angola, IN 46703 – 1945
(260) 668-1000 ext. 2220
SULLIVAN
Sullivan Co. Circuit Court Clerk
P.O. Box 370
Sullivan, IN 47882 - 0370
(812) 268-4657
SWITZERLAND
Switzerland Co. Circuit Court Clerk
Courthouse
212 West Main
Vevay, IN 47043 - 1180
(812) 427-4415
TIPPECANOE
Tippecanoe Co. Circuit Court Clerk
P.O. Box 1665
Lafayette, IN 47902
(765) 423-9316
TIPTON
Tipton Co. Circuit Court Clerk
101 East Jefferson
Tipton, IN 46072 - 1901
(765) 675-2795
UNION
Union Co. Circuit Court Clerk
26 West Union Street
Liberty, IN 47353 - 1396
(765) 458-6121
VANDERBURGH
Vanderburgh Co. Circuit Court Clerk
P.O. Box 3356
Evansville, IN 47732 - 3356
(812) 435 - 5160
VERMILLION
Vermillion Co. Circuit Court Clerk
P.O. Box 10
Newport, IN 47966 - 0008
(765) 492-5350
VIGO
Vigo Co. Circuit Court Clerk
33 S 3
rd
St.
Terre Haute, IN 47808
(812) 462-3211
WABASH
Wabash Co. Circuit Court Clerk
69 West Hill Street
Wabash, IN 46992
(260) 563-0661 ext. 230
WARREN
Warren Co. Circuit Court Clerk
125 North Monroe Street
Suite 11
Williamsport, IN 47993 - 1198
(765) 762-3510
WARRICK
Warrick Co. Circuit Court Clerk
1 County Square
Suite 200
Boonville, IN 47601 - 1594
(812) 897-6163
WASHINGTON
Washington Co. Circuit Court Clerk
99 Public Square, Ste 102
Salem, IN 47167
(812) 883-5748
WAYNE
Wayne Co. Circuit Court Clerk
301 E. Main Street
Richmond, IN 47374
(765) 973-9224
WELLS
Wells Co. Circuit Court Clerk
102 West Market Street
Suite 201
Bluffton, IN 46714 - 2091
(260) 824-6482
WHITE
White Co. Circuit Court Clerk
P.O. Box 350
Monticello, IN 47960 - 0350
(866) 918-8683
WHITLEY
Whitley Co. Circuit Court Clerk
101 West Van Buren Street
Columbia City, IN 46725 - 2087
(260) 248-3102
INDIANA ELECTION DIVISION
302 West Washington St., RM E204
Indianapolis, IN 46204
(800) 622-4941
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ApplicationForAbsenteeBallot - 42106

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Completed 7 December 2019

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