Voter’s name and
address
1
Voter’s Full Name
Street Address
City/Town State
County Zip Code
Voter’s Signature
2
I hereby authorize the representative designated below to pick up and/or return my emergency absentee
ballot. I agree that:
• My representative is only allowed to pick up and/or return my completed ballot that I have sealed in the
required envelopes addressed to my County’s Board of Elections.
• My completed ballot must be returned to the Board of Elections by 8:00 p.m. on election day.
Voter Signature X Date
Representative’s
name and address
3
Representative’s Full Name
Street Address
City/Town State
County Zip Code
Representative’s
Signature
4
I hereby agree to serve as the designated representative for the above-named voter. I agree that:
• I am only this voter’s designated representative for the purposes of obtaining and/or returning their
emergency absentee ballot.
• If returning the voter’s ballot, I will do so only after it has been completed by the voter and sealed in the
required envelope.
Representative’s Signature X Date
DOS-05/2020
Authorize a Representative to Pick up
and/or Return Emergency Absentee Ballot
If you are unable to pick up and/or return your emergency absentee ballot yourself, this form allows
you to authorize a representative to do it for you.
The voter or authorized representative must return this form and the ballot to the County Board of
Elections by 8:00 p.m. on election day.
Visit VotesPA.com/mailballot or call 1-877-868-3772 for more information.
I authorize a representative to pick up and/or return my emergency
absentee ballot to my County Board of Elections.
