EMERGENCY ABSENTEE BALLOT
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.
Only in the case of a medical emergency may a voter 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]. Also in the case of a medical emergency, the voter’s designee may hand this application to the Absentee
READ PENALTIES ON BACK
Print Witness Name
section if voter
signs by mark
Street Address (address where you are registered to vote; do not use PO box)
Mail my ballot to the address where I regularly receive mail, 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
For all registered voters
PHYSICIAN’S REPORT FOR MEDICAL EMERGENCY
Physician shall describe and certify the circumstances as constituting the emergency.
Physician’s Signature Date
I will be unable to vote at my regular polling place on election day because (check one reason):
I have a medical emergency. Complete the Physician’s Report below. The physician’s report must be signed by a physician. [If
the physician’s report is on a separate document, attach it to this application. This application may be delivered by a designee. If
assigning a designee, complete the designee section at the bottom of this form.]
I am required by my employer under unforeseen circumstances within ve days before an election to be unavailable to vote at the
polls on election day. [The voter must deliver the application by hand to the Absentee Election Manager no later than the day prior
to the election.]
I am a caregiver of a person who requires emergency treatment by a licensed physician within ve days before an election. [The
voter must deliver the application by hand to the Absentee Election Manager no later than the day prior to the election.]
A family member to the second degree of kinship by afnity or consanguinity died within ve days before an election. [The voter
must deliver the application by hand to the Absentee Election Manager no later than the day prior to the election.]
Last Name (Please print)
First Name Middle or Maiden Name
Driver’s License Number
IF NO DRIVER’S LICENSE NUMBER
Last 4 digits of
Return this application to:
Primary Election or Presidential Preference Primary
I hereby make application for an absentee ballot so that I may vote in the following election:
Primary Runoff Election
Special Election (specify) ________________________
n Absentee ballots for elections more than 42 days apart must be requested on separate applications, unless you are a member of the armed forces, or a
spouse or dependent of such person, or you are a United States citizen residing overseas, or are permanently disabled.
n An application submitted by a member of the armed forces, or a spouse or dependent of such person, or a United States citizen residing overseas is
valid for all county, state and federal elections in the current calendar year. An application submitted by a citizen with a permanent disability is valid for all
municipal, county, state, and federal elections in the current calendar year.
If a primary or runoff, check one:
Please note that a copy of your valid photo identication must be submitted with this application.
ASSIGNMENT OF DESIGNEE FOR DELIVERY OF APPLICATION
An application for an emergency medical absentee ballot may be forwarded to the Absentee Election Manager by the applicant or his or her designee. If
assigning a designee, complete this section.
Printed Name of Designee Signature of Designee
For Ofce Use Only
______________________ COUNTY, ALABAMA
Please note that only one application may be placed in the same envelope.
Date Revised 07/29/2019
General Voter Information - Please provide complete information so that we may verify your eligibility to vote.