How to submit your application:
Once your application is completed, you may
return it to your local county board of elections. If you’re
unsure of where to mail your application, please visit www.vote.pa.gov/County for more information.
Necessary identication:
The deadline to apply for a civilian absentee ballot is
5:00PM on the Tuesday before the election. Please note
your application must be received in the county board of
election’s oce by that time. Postmarks do not count.
The deadline to return your completed ballot is
8:00PM on election day. Please note your completed
ballot must be received by the county board of elec-
tion’s by that time. Postmarks do not count.
Deadline alert:
Questions?
Call your County
Election Office
or call 1-877-868-3772.
For more information about
voting, visit our website:
www.vote.pa.gov
Información en español:
Si le interesa obtener este
formulario en español, llame al
1-877-868-3772.
In order to apply for an absentee ballot, you must supply your PA Driver’s License or PennDOT issued photo ID
card number in the Identication section. If you do not have a PA Driver’s License or PennDOT issued photo ID
card, you must supply the last four (4) digits of your Social Security number.
If you do not have a valid form of either of these types of identication, please check the box titled “I do not have
a PA driver’s license or a PennDOT ID card or a Social Security number” in the Identication section. If you
choose this option, you must enclose a photocopy of an acceptable ID.
Please visit www.vote.pa.gov/MailBallot for more information, call 1-877-868-3772, or contact your county
board of elections.
What is an annual absentee ballot request?
If you have a permanent illness or a permanent disability you may be added to the annual absentee request
list. Once your physician signs the certication of permanent disability and your request is approved, you will
automatically receive ballots for the remainder of the year, and you will receive an application to renew your
request for absentee ballots each year.
If you update your voter registration due to relocation out of county after you submit an annual absentee ballot
request, please ensure your annual status is transferred when updating your address.
Assistance in voting:
If you require assistance with completing your ballot due to a disability, you must also complete a Statement of
Absentee Elector Requiring Assistance form. Please visit www.vote.pa.gov for more information.
WARNING: If you receive an absentee ballot and return your voted ballot by the deadline,
you may not vote at your polling place on election day. If you are unable to return your voted
absentee ballot by the deadline, you may only vote a provisional ballot at your polling place on
election day, unless you surrender your absentee ballot and the return envelope containing the
Voters Declaration to the judge of elections to be voided to vote by regular ballot.
A
Page 1
07.2021
Pennsylvania Application for Absentee Ballot
WARNING: If you receive an absentee ballot and return your voted ballot by the deadline, you may not vote at your polling place on election day. If you are unable to return
your voted absentee ballot by the deadline, you may only vote a provisional ballot at your polling place on election day, unless you surrender your absentee ballot and the return
envelope containing the Voter’s Declaration to the judge of elections to be voided to vote by regular ballot.
Pennsylvania Application for Absentee Ballot
A
Page 1
07.2021
Print name
Please print your name
exactly as registered.
1
Last name
Jr Sr ll lll lV
First name
Middle name or initial
About you
Phone & email are option-
al & used if information is
missing on this form.
2
Email
Birth date (required)
Phone number
I do not have a PA driver’s license or a PennDOT ID card or a Social Security number.
Identication
If you have a PennDOT
number, you must use it. If
not, please provide the last
four digits of your Social
Security number. See
“Necessary Identication”
instructions page.
5
Last four digits of your Social Security number X X X - X X -
PA driver’s license or PennDOT ID card number
I hereby apply for an absentee ballot for the following reason:
I will be absent from my municipality (Complete section A) I have an illness or physical disability (Complete section B)
Reason
Select a reason for apply-
ing for an absentee ballot.
6
Help with this
form
Complete this section
if you are unable to
sign in Section B1
because of illness or
physical disability. See
“Assistance in voting”.
B2
I hereby state that I am unable to sign my application for an absentee ballot without assistance because I am unable to write by
reason of my illness or physical disability. I have made, or have received assistance in making my mark in lieu of my signature.
Mark of voter X
Address of witness
Signature of witness X
Date
Section A
Absence from
municipality
A
Reason for absence
Voter signature here X
Date
I declare that I am eligible to vote absentee at the forthcoming primary or election since I expect that my duties, occupation
or business will require me to be absent from the municipality of my residence on the day of the primary or election for the
reason stated below; and that all of the information which I have listed on this absentee ballot application is true and correct.
Where to mail
ballot?
4
Address or PO BoxSame as above
This address is my (e.g. vacation home, temporary residence, etc.)
City ZipState
Voting district or
precinct (if known) Municipality Ward (if known)
Your address
Please print your
address exactly as reg-
istered. If your address
has changed, you should
rst update your voter
registration. The deadline
to update your address is
15 days before the date
of the next election.
3
I have lived at this address since
Address (not P.O. Box)
Apt. number
City
Zip
County
State
PA
Are you a State or Federal Government employee? Yes No
Physician oce address
Voter signature here X
Date
Section B –
Illness/
Physical
disability
B1
I declare that I am eligible to vote absentee at the forthcoming primary or election due to the illness or physical disability
stated below; that the information required to be listed pertaining to my attending physician is correctly stated herein; and
that all other information which I have listed on this absentee ballot application is true and correct.
Nature of illness or physical disability
Physician phone
Physician name
WARNING: If you receive an absentee ballot and return your voted ballot by the deadline, you may
not vote at your polling place on election day. If you are unable to return your voted absentee ballot
by the deadline, you may only vote a provisional ballot at your polling place on election day, unless
you surrender your absentee ballot and the return envelope containing the Voter’s Declaration to
the judge of elections to be voided to vote by regular ballot.
A
Page 3
07.2021
Section C (Optional): Annual Absentee Ballot Request Because of
Permanent Illness or Permanent Disability and Physician’s Certication
(to be completed with your Physician below)
If you are a voter with a permanent illness or a permanent disability, you may request to be placed on an annual absentee ballot list. See
“What is an annual absentee ballot request?” on Page 3.
You need only le a physician’s certicate of permanent illness or permanent disability once. Once your disability status has been
certied by your physician, your physician will not need to recertify your disability status, and you will be placed on the annual absentee
voter list.
If you are approved as an annual absentee voter, you will recieve an application to renew your request for absentee ballots each year.
If you lose your disability status, you must inform your county board of elections.
If you update your voter registration due to relocation out of county after you submit an annual absentee ballot request, please ensure
your annual status is transferred when updating your address.
Annual
absentee
request
See “What is an
annual absentee ballot
request?” for more
information.
C1
If you would like to receive absentee ballots for the remainder of this year and if you would like to automatically receive
an annual application to automatically receive absentee ballots each year, please indicate below.
If you update your voter
registration due to relocation out of county after you submit an annual absentee ballot request, please ensure your annual status is
transferred when updating your address.
I would like to receive absentee ballots this year and receive annual applications for absentee ballots each year.
(Please have your physician sign the certification in Section C2.)
Date
Certicate of
permanent
illness or
permanent
physical
disability
Have your physician
sign this certication
if you indicated you
would like to be an
annual absentee voter
in section C1.
C2
I hereby certify that the above named voter is permanently disabled, and either physically unable to attend the polls or
physically unable both to operate a voting machine (or mark the ballot) and to orally request assistance to do so.
Signature of physician X
Print physician name
Pennsylvania Application for Absentee Ballot
Adams
117 Baltimore St
Rm 106
Gettysburg PA 17325
(717) 337-9832
Allegheny
542 Forbes Ave
Ste 609
Pittsburgh PA 15219-2913
(412) 350-4500
Armstrong
Administration Bldg
450 E Market St
Ste 207
Kittanning PA 16201
(724) 548-3222
Beaver
810 Third St
Beaver PA 15009
(724) 770-4440
Bedford
200 S Juliana St
3rd Fl
Ste 301
Bedford PA 15522
(814) 623-4807
Berks
633 Court St
1st Fl
Reading PA 19601
(610) 478-6490
Blair
279A Loop Road
Hollidaysburg PA 16648
(814) 693-3287
Bradford
6 Court St
Ste 2
Towanda PA 18848
(570) 265-1717
Bucks
55 E Court St
Doylestown PA 18901-4318
(215) 348-6163
Butler
PO Box 1208
Butler PA 16003
(724) 284-5308
Cambria
200 S Center St
Ebensburg PA 15931
(814) 472-1464
Cameron
20 E Fifth St
Emporium PA 15834-1469
(814) 486-9321
Carbon
410 Center Ave
Jim Thorpe PA 18229-0170
(570) 325-4801
Centre
420 Holmes St
Willowbank Oce Bldg
Bellefonte PA 16823-1486
(814) 355-6703
Chester
601 Westtown Rd
Ste 150
PO Box 2747
West Chester PA 19380-0990
(610) 344-6410
Clarion
Administrative Building
330 Main St
Rm 104
Clarion PA 16214
(814) 226-4000 Ext 2006
Cleareld
212 E Locust St
Ste 106
Cleareld PA 16830
(814) 765-2642 ext 5053
Clinton
2 Piper Way
Ste 309
Lock Haven PA 17745
(570) 893-4019
Columbia
PO Box 380
Bloomsburg PA 17815-0380
(570) 389-5640
Crawford
903 Diamond Park
Meadville PA 16335
(814) 333-7307
Cumberland
1601 Ritner Highway
Ste 201
Carlisle PA 17013
(717) 240-6385
Dauphin
PO Box 1295
Harrisburg PA 17108-1295
(717) 780-6360
Delaware
Govt Center Bldg
201 W Front St
Media PA 19063-2728
(610) 891-4659
Elk
300 Center St
PO Box 448
Ridgway PA 15853-0448
(814)776-5337
Erie
140 W 6th St
Rm 112
Erie PA 16501
(814) 451-6276
Fayette
22 E Main St
Public Service Bldg
Uniontown PA 15401
(724) 430-1289
Forest
526 Elm St
Box 3
Tionesta PA 16353
(814) 755-3537
Franklin
157 Lincoln Way East
Chambersburg PA 17201-2211
(717) 261-3886
Fulton
116 W Market St
Ste 205
McConnellsburg PA 17233
(717) 485-6872
Greene
93 E High St
Rm 102
Waynesburg PA 15370
(724) 852-5230
Huntingdon
Bailey Building
233 Penn St
Huntingdon PA 16652-1486
(814) 643-3091 Ext 205
Indiana
825 Philadelphia St
Indiana PA 15701-3934
(724) 465-3852
Jeerson
155 Main St
Jeerson Place
Brookville PA 15825-1269
(814) 849-1693
Juniata
1 N Main St
PO Box 68
Miintown PA 17059
(717) 436-7706
Lackawanna
123 Wyoming Ave
2nd Floor
Scranton PA 18503
(570) 963-6737
Lancaster
PO Box 2139
Lancaster PA 17608
(717) 299-8293
Lawrence
430 Court St
New Castle PA 16101
(724) 656-2161
Lebanon
400 S 8th St
Municipal Bldg
Rm 209
Lebanon PA 17042
(717) 228-4428
Lehigh
17 S 7th St
Allentown PA 18101-2401
(610) 782-3194
Luzerne
20 N Pennsylvania Ave
Ste 207
Wilkes-Barre PA 18701
(570) 825-1715
Lycoming
48 W Third St
Williamsport PA 17701-9536
(570) 327-2267
McKean
500 W Main St
Smethport PA 16749
(814) 887-3203
Mercer
5 Courthouse
Mercer PA 16137-1227
(724) 662-7542
Miin
20 N Wayne St
Lewistown PA 17044
(717) 248-6571
Monroe
One Quaker Plaza
Rm 105
Stroudsburg PA 18360
(570) 517-3165
Montgomery
Voter Services
PO Box 311
Norristown PA 19404-0311
(610) 278-3280
Montour
253 Mill St
Danville PA 17821
(570) 271-3002
Northampton
Elections Division
669 Washington St
Easton PA 18042
(610) 829-6260
Northumberland
320 N 2nd St
Ste 1
Sunbury PA 17801
(570) 988-4208
Perry
PO Box 37
New Bloomeld PA 17068
(717) 582-2131 ext 4110
Philadelphia
City Hall, Room 142
1400 John F Kennedy Blvd
Philadelphia, PA 19107
(215) 686-3469
Pike
506 Broad St
Milford PA 18337
(570) 296-3427
Potter
1 N Main St
Ste 204
Coudersport PA 16915
(814) 274-8467
Schuylkill
420 N Centre St
Pottsville PA 17901
(570) 628-1467
Snyder
PO Box 217
Middleburg PA 17842-0217
(570) 837-4207
Somerset
300 N Center Ave
Ste 340
Somerset PA 15501
(814) 445-1549
Sullivan
245 Muncy St
PO Box 157
Laporte PA 18626
(570) 946-5201 ext 7
Susquehanna
PO Box 218
31 Lake Ave
Montrose PA 18801
(570) 278-6697
Tioga
118 Main St
Wellsboro PA 16901
(570) 723-8230
Union
155 N 15th St
Lewisburg PA 17837-8822
(570) 524-8681
Venango
1174 Elk St
PO Box 831
Franklin PA 16323-0831
(814) 432-9514
Warren
204 4th Ave
Warren PA 16365
(814) 728-3406
Washington
100 W Beau St
Rm 206
Washington PA 15301
(724) 228-6750
Wayne
925 Court St
Honesdale PA 18431
(570) 253-5978
Westmoreland
2 N Main St
Ste 109
Greensburg PA 15601
(724) 830-3150
Wyoming
1 Courthouse Sq
Tunkhannock PA 18657
(570) 996-2226
York
28 E Market St
York PA 17401-1579
(717) 771-9604
For a listing of available
email addresses, go to
www.vote.pa.gov/county.
PA-DOS COAD 01.2021
Pennsylvania County Election Oce addresses