APPLICATION FOR PERMANENT DISABILITY
ABSENTEE BALLOT
FOR USE ONLY BY INDIVIDUALS VOTING ABSENTEE DUE TO A
PERMANENT DISABILITY
When I apply for this absentee ballot, I understand that my name will be stricken from the list of qualied electors and,
when I cast this absentee ballot, I understand that I will not be entitled to vote at my regular polling place.
The voter may hand this application to the Absentee Election Manager. The voter may also forward this application to the
Absentee Election Manager by U.S. Mail or commercial carrier [§17-11-3 and §17-11-4, Code of Alabama, 1975].
READ PENALTIES ON BACK
Voter’s Signature
Witness Signature
Print Witness Name
Complete this
section if voter
signs by mark
If requesting mail delivery of a ballot, provide a mailing address, if different from the street address provided above
Precinct where you vote (name and/or location of your polling place)
Work Telephone Number
Date of Birth
Home Telephone Number
By signing this application, I am attesting that I am
permanently disabled and unable to attend the polls. I am
eligible to vote absentee pursuant to Act 2019-359.
I understand that this application will be valid for all county,
state, and federal elections to be held during this calendar
year. For election cycles that span multiple calendar years,
this application will be valid for the entire election cycle.
I further understand that annual renewal of this application will
be required.
Type of Ballot (select one) Reason for Applying to Vote Absentee
Street Address (address where you are registered to vote; do not use PO box)
City
ZIP
YearDayMonth
( )
( )
Last Name (Please print)
First Name
Middle or Maiden Name
Driver’s License Number
Return this application to:
STATE
NUMBER
IF NO DRIVER’S LICENSE NUMBER
Last 4 digits of
Social Security
number
E-mail Address
FORM AV-D1
Date Revised 07/23/2019
Primary Election or Presidential Preference Primary
Select one:
Democratic Party
Republican Party
Other ____________
Amendments Only
Primary Runoff Election
Select one:
Democratic Party
Republican Party
Other ____________
Amendments Only
General Election
Special Election (specify) _________________
Physician’s Report (Please note that the physician’s signature must be notarized)
Democratic Party
Republican Party
If a primary or runoff, check one:
Physician shall describe and certify the circumstances as constituting the voter’s condition.
Physician’s Signature
Date
Sworn to and subscribed before me this ______ day of ________,
20___. I certify that the afant is known (or made known) to me to
be the identical party he or she claims to be.
Signature of Notarizing Ofcial
Title of Notarizing Ofcial
Please note that a copy of your valid photo identication must be submitted along with this application.
Please note only one application may be placed in the same envelope.
______________________________ COUNTY, ALABAMA
General Voter Information - Please provide complete information so that we may verify your eligibility to vote.
