Iowa Driver’s License or Non-Operator ID Number:
ABS SEQ NUM: _______
REG: OK _____ NR _____ CH _____
SPLIT: ________________________
BALLOT #: _____________________
Revised October 2019
PrimaryGeneral
City/School
Requester Affidavit
Primary Election
Only
Election Date or
Type
Important
Contact Info
Voters who do not appear in the Iowa Dept. of
Transportation's Driver's License or
Non-Operator ID files are mailed an Iowa Voter
Identification Card at the time of registration.
Any voter may request a Voter Identification Card.
X
Four-digit Voter PIN (can be found on Voter Identification Card):
OR
F
OR
O
FFICE
U
SE
O
NLY
Your Name and
Date of Birth
Middle
Suffix
ID Number
Your Iowa
Residential
Address
You must be registered to vote in the county to receive an absentee ballot. If you are registered to vote in the county, this form will be used to update
your voter registration if the information provided on this form is different than the information on your registration record.
Home Street Address
(include apt, lot, etc. if applicable)
City Zip County
Where Your
Absentee Ballot
Should Be Mailed
If different than above
Mailing Address/P.O. Box
Phone
Email
Special:
OR
Do not add this contact
info to my voter record
Election
Check one political party
Democratic Republican
Powers of attorney do not
have legal authority to
request an absentee ballot
on behalf of another.
I swear or affirm that I am the person named above and I am a registered voter or I am entitled to register at the address listed on this form.
I am eligible to receive and vote an absentee ballot for the election indicated above.
Signature:
Date
S
TATE OF
I
OWA
O
FFICIAL
A
BSENTEE
B
ALLOT
R
EQUEST
F
ORM
City State Zip
Country (other than USA)
Date of Birth
(month, day, year)
First
Last
//
/
/
Voters without an Iowa Driver’s License or Non-Operator ID number are mailed an Iowa Voter Identification Card at the time of registration.
Choose only one election.
Step 2: Fold Here
Instructions:
1) This form is used to request an Absentee Ballot. You must
complete a new form for each election.
2) Sign and date the form. Forms must be signed by the voter.
Can't I just email or fax you my completed form? Yes, but you still
need to send the original signed document to the address above.
We can mail out a ballot from a scanned or faxed request. However,
in order for a ballot to be counted, the original signed request is
required.
3) Please user clear tape when sealing the form. Place tape at the
locations indicated by a after folding.
Election Types
General - presidential or gubernatorial election. These elections are
held in November of even-numbered years.
Primary - partisan primary held in June in even-numbered years to
nominate candidates for a General Election.
City/School - held in November of odd-numbered years.
Special - held when needed and as allowed by law.
Note: This form is Story County only. If the Business Reply Mail address on
this form is changed or altered it will not be delivered.
Step 1: Fold Here
NO POSTAGE
NECESSARY
IF MAILED
IN THE
UNITED STATES
BUSINESS REPLY MAIL
FIRST-CLASS MAIL PERMIT NO. 33 NEVADA IA
POSTAGE WILL BE PAID BY ADDRESSEE
LUCY MARTIN
STORY COUNTY AUDITOR
900 6TH ST STE 3
NEVADA IA 50201-9912
ABSENTEE BALLOT REQUEST FORM
