DO NOT REMOVE PERFORATED TABS. Moisten here and fold bottom to top to seal. DO NOT REMOVE PERFORATED TABS. Moisten here and fold bottom to top to seal.
Application for Ballot by Mail
Prescribed by the Ofce of the Secretary of State of Texas
A5-15 12/17
For Ofcial Use Only
VUID #, County Election Precinct #,
Statement of Residence, etc.
1
Last Name (Please print information) Sufx (Jr., Sr., III, etc) First Name Middle Initial
2
Residence Address: See back of this application for instructions.
City
,TX
ZIP Code
3
Mail my ballot to: If mailing address differs from residence address, please complete Box # 7.
City State ZIP Code
4
Date of Birth (mm/dd/yyyy) (Optional)
Contact Information (Optional)*
Please list phone number and/or email address:
* Used in case our ofce has questions.
5
Reason for Voting by Mail:
65 years of age or older. (Complete Box #6a)
Disability. (Complete Box #6a)
Expected absence from the county. (Complete Box #6b and Box #8)
You will receive a ballot for the upcoming election only
Connement in jail. (Complete Box #6b)
You will receive a ballot for the upcoming election only
6a
ONLY Voters 65 Years of Age or Older or Voters with a Disability:
If applying for one election, select appropriate box.
If applying once for elections in the calendar year, select “Annual Application.”
Annual Application
Uniform and Other Elections:
May Election
November Election
Other
___
Primary Elections:
You must declare one political party to vote in
a primary:
Democratic Primary
Republican Primary
Any Resulting Runoff
6b
ONLY Voters Absent from County or Voters Conned in Jail:
You may only apply for a ballot by mail for one election, and any resulting runoff.
Please select the appropriate box.
Uniform and Other Elections:
May Election
November Election
Other _
___
Primary Elections:
You must declare one political party to vote in
a primary:
Democratic Primary
Republican Primary
Any Resulting Runoff
7
If you are requesting this ballot be mailed to a different address (other than residence), indicate where the ballot
will be mailed. See reverse for instructions.
Mailing Address as listed on my voter registration certicate
Nursing home, assisted living facility, or long term care facility
Hospital
Retirement Center
Address of the jail
Relative; relationship __
Address outside the county (see Box #8)
___
8
If you selected “expected absence from the county,” see reverse for instructions
Date you can begin to receive mail at this address Date of return to residence address
9
Voters may submit a completed, signed, and scanned application to the Early Voting Clerk at:
(early voting clerk’s e-mail address ) (early voting clerk’s fax)
NOTE: If you fax or e-mail this form, please be aware that you must also mail the form to the early voting clerk within four
business days. See “Submitting Application” on the back of this form for additional information.
10
“I certify that the information given in this application is true, and I understand that giving false information
in this application is a crime.”
X
Date
SIGN HERE
If applicant is unable to sign or make a
mark in the presence of a witness, the
witness shall complete Box #11.
If someone helped you to complete this form or mails the form for you, then that person must complete the sections below.
11
See back for Witness and Assistant denitions.
If applicant is unable to mark Box #10 and you are acting as a Witness to that fact, please check this box and sign below.
If you assisted the applicant in completing this application in the applicant’s presence or e-mailed/mailed or faxed the application on behalf of the applicant, please check this box as an Assistant and sign below.
*
If you are acting as Witness and Assistant, please check both boxes.
Failure to complete this information is a Class A misdemeanor if signature was witnessed or applicant was assisted in completing the application.
X
Signature of Witness /Assistant
Street Address Apt Number (if applicable)
State
X
Printed Name of Witness/Assistant
City
ZIP Code
(Refer to Instructions on back for clarification)
Witness’ Relationship to Applicant
Este formulario está disponible en Español. Para conseguir la version en Español favor de llamar sin cargo al 1.800.252.8683 a la ocina del Secretario de Estado o la Secretaria de Votación por Adelantado.
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