Fillable Form 07.2021: M (Pennsylvania)

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Form 07.2021: M (Pennsylvania)

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The Form 07.2021: M (Pennsylvania) form is 2 pages long and contains:

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Country of origin: US
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How to submit your application:
Once your application is completed, you may ret
urn 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 mail-in 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
election’s by that time. Postmarks do not count.
Deadline alert:
Questions?
Call your County
Election O ice
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 a mail-in 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 mail-in ballot request?
If you indicate you would like to be added to the annual mail-in ballot request list, you will receive an applica-
tion to renew your request for mail-in ballot each year. Once your application is approved, you will automatical-
ly receive ballots for the remainder of the year and you do not need to submit an application for each election.
If you update your voter registration due to relocation out of county after you submit an annual mail-in ballot
request, please ensure your annual status is transferred when updating your address.
WARNING: If you receive a mail-in 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 mail-in
ballot by the deadline, you may only vote a provisional ballot at your polling place on election
day, unless you surrender your mail-in ballot and the return envelope containing the Voter’s
Declaration to the judge of elections to be voided to vote by regular ballot.
M
Page 1
07.2021
Pennsylvania Application for Mail-in Ballot
M
Page 2
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 and email are
optional and 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 “Nec-
essary 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
Help with this
form
Complete this section
if you are unable to
sign the declaration in
Section 6.
8
I hereby state that I am unable to sign my application for a mail-in 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
Declaration
6
Voter signature here X
Date
I declare that I am eligible to vote by mail-in ballot at the forthcoming primary or election; that I am requesting the ballot of
the party with which I am enrolled according to my voter registration record; and that all of the information which I have listed
on this mail-in ballot application is true and correct.
Annual mail-in
request
See “What is an annual
mail-in ballot request?”
for more information.
7
I would like to receive mail-in ballots this year and receive annual applications for mail-in ballots each year.
If you would like to apply to receive mail-in ballots for the remainder of this year and if you would like to automatically receive an
annual application for mail-in ballots each year, please indicate below. If you update your voter registration due to relocation out of
county after you submit an annual mail-in ballot request, please ensure your annual status is transferred when updating your address.
Voting district or
precinct (if known) Municipality Ward (if known)
Your address
Please print your
address exactly as
registered. 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
City
I have lived at this address since
Zip
Address (not P.O. Box)
Apt. number
County
State
PA
Where to mail
ballot?
4
Address or PO Box
Same as above
This address is my (e.g. vacation home, temporary residence, etc.)
City
ZipState
Pennsylvania Application for Mail-in Ballot
WARNING: If you receive a mail-in 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 mail-in ballot by the deadline, you may only vote a provisional ballot at your polling place on election day, unless you surrender your mail-in ballot and the return
envelope containing the Voter’s Declaration to the judge of elections to be voided to vote by regular 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
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Form 07.2021: M (Pennsylvania)

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Completed 9 September 2021

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