APPLICATION FOR ABSENTEE BALLOT
You are receiving this application for an absentee ballot because, due to COVID-19, the
Secretary of the State has sent an application to every eligible voter. Pursuant to PA 20-3
July Spec. Sess., COVID-19 may be used as a valid reason for requesting a ballot.
Section I. – A
Name: Date of B
Home Address: Z
(Number, Street, Town)
Telephone No. E-m
if the mailing address is different from the address above.)
Section II. – Statement of Applicant - Required
I, the undersigned applicant, believe that I am eligible to vote at the November 3, 2020 election
pursuant to Public Act 20-3 July Spec. Sess., I expect to be unable to appear at the polling place during the hours of voting and hereby
apply for an absentee ballot: (you MUST check one)
□ COVID-19 ► All voters are able to check this box, pursuant to Public Act 20-3 July Spec. Sess.◄
□ My active service in the Armed Forces of the United States
□ My absence from the town during all of the hours of voting
□ My illness
My religious tenets forbid secular activity on the day of the election, primary or referendum
□ My duties as a primary, election or referendum official at a polling place other than my own during all of the hours of voting
□ My physical disability
Personnel only, please indicate if you would like your absentee ballot sent to you electronically to the email address
provided above (Yes__ No __)
Section III. – Ap
plicant’s Declaration - Required
I declare, under the penalties of false statement in absentee balloting, that the above statements are true and correct, and that I am the
applicant named above.
(Sign your legal name in full. If you are unable to write, you may authorize some one to write your name and the date in the spaces
provided, followed by the word “by” and the signature of the authorized person. Such person must also complete section IV below.)
Signature of Appl
icant: Date Signed:
Section IV. – Dec
laration of person providing assistance
(Completed by any person who assists with completion of application)
I sign this application under penalties of false statement in absentee balloting.
ted Name: Tel. No:
Connecticut law allows you to receive an absentee ballot if you cannot appear at your assigned polling place on election day
because of active service in the Military, absence from the town during all of the hours of voting, illness, religious tenets forbid
secular activity on the day of the election, duties as an election official at a polling place other than your own during all of the
hours of voting, or physical disability. The State of Connecticut, via P.A. 20-3 July Spec. Sess. has determined that the existence of
the COVID-19 virus allows you to vote by absentee ballot if you so choose for your own safety. To receive your absentee ballot
please complete and sign this application and return it to your Town Clerk using the enclosed postage prepaid envelope. Your
absentee ballot will be mailed to you beginning October 2, 2020.
l Clerk’s Use
Outer Envelope Serial No.
Voter ID No.