Fillable Form 1.: 2021 Minnesota Absentee Ballot Application (Hennepin County)

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Form 1.: 2021 Minnesota Absentee Ballot Application (Hennepin County)

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2021 Minnesota Absentee Ballot Application
Complete lines 1 through 7 below. Please print clearly.
Return this application as soon as possible. Ballots must be returned by election day to be counted.
Important: Active duty military and overseas voters should not use this application. See the other side for more information.
1.
absentee ballots requested for the following elecon(s) (if no elecon is marked, a ballot will be mailed for the next elecon only)
2/9 Special Election
3/9 Township Election
4/13 Special Election
5/11 Special Election
8/10 Primary Election
11/2 General Election
Both 8/10 & 11/2 Elections
Other (specify date):
2.
last name or surname
rst name
middle name sux
3.
date of birth (mm/dd/yyyy)
county where you live phone number
email address
4.
mark all boxes that apply:
I have a MN-issued driver’s license or MN ID card. The number is:
I have a social security number. The last four digits are: XXX-XX-
I do not have a MN-issued driver’s license, MN-issued ID card or a social security number.
Your idencaon number will be compared to the one on your absentee ballot envelope.
5.
address where you live (residence)
apt. city
MN
zip code
6.
address where your absentee ballot should be sent apt. city state zip code
7.
I certify that I:
am completing this application on my own behalf;
will be at least 18 years old on election day;
am a citizen of the United States;
will have resided in Minnesota for 20 days immediately preceding election day;
maintain residence at the address given on this application form;
am not under court-ordered guardianship in which the court order revokes my right to vote;
have not been found by a court to be legally incompetent to vote;
have the right to vote because, if I have been convicted of a felony, my felony sentence has expired (been completed) or I
have been discharged from my sentence; and
have read and understand this statement: The above information is accurate, and I sign this application form under penalty
of perjury, a felony punishable by not more than 5 years imprisonment, a fine of not more than $10,000, or both.
school district
precinct
reg
non-reg
ocial use only
received date inials
ballot issued date
reg
non-reg
Primary
General received date inials
ballot issued date type
M C HCF
type
M C HCF
repl. date:
reason replaced
rejected lost
spoiled
never received
repl. date:
reason replaced
rejected lost
spoiled
never received
See other side for special instrucons for voters with disabilies or power of aorney.
sign here: X__________________________ date ____/____/____
- -
Return this application as soon as possible to:
Hennepin County Elections
Government Center
300 S. 6th St MC 012
Minneapolis MN 55487-0012
hc.vote@hennepin.us
Where to return your applicaon
You should return this to your local election office. If not
provided above, contact information for your local election
official can be found under “Find County Election Office”
at http://www.mnvotes.org.
Options for returning absentee ballot applications
For federal, state or county elections, submit an absentee
ballot application online at http://www.mnvotes.org. -OR-
Paper absentee ballot applications may be returned by
mail, fax or as a scanned attachment to an email.
When your ballot will be sent
Your absentee ballot materials will be sent to you at least
46 days before the elecon, (excluding town elecons held
in March where materials will be sent 30 days before the
elecon). If you applied aer this date, your ballot will be
sent when the applicaon is received. Contact your local
elecon ocial if you have not received your ballot. To
check the status of your absentee ballot, visit
http://www.mnvotes.org.
Privacy Notice
Your exact date of birth, email address, and any ID
number you give (Minnesota driver's license, state ID or
last four digits of social security number) are private. Only
election officials may access it.
Election officials ask for your exact date of birth so they can
match your application to your voter record. If you refuse to
give your date of birth, you won’t get an absentee ballot.
Election officials ask for your email so they can contact you
about your application. Also, the Office of the Secretary of
State may email you (or contact you another way) about
voting and elections, or ask for public input. If you refuse to
give an email address, you cannot apply for an absentee
ballot online and you will need to apply with a paper
application.
Election officials ask for an ID number to check that the
person who is casting the ballot is the same person who
applied for it. If you have an ID number but refuse to give it,
your absentee ballot might get rejected, and you won’t be
able to check your absentee ballot status online.
The rest of the data on your application is public when used
for elections, political or law enforcement purposes. If you
need to keep your contact data private because of personal
safety concerns, call 1-877-600-8683 to learn what you can
do.
Who may apply for a ballot
Each person must apply for themselves. It is a felony to
make a false statement in an application for an absentee
ballot, to aempt to cast an illegal ballot, or to help anyone
to cast an illegal ballot.
If you think you may not be registered to vote
If you are not registered at the legal residence address
provided, you will be sent a voter registraon applicaon
with your ballot materials.
Information for active-duty military and overseas
voters
If you are applying for an absentee ballot because you or
your family are acve-duty military or because you will be
overseas and/or outside of the territorial limits of the
United States, do not use this applicaon. You are entled
to special protecons if you apply using the Federal
Postcard Application. For more information and to apply
online, go to http://www.mnvotes.org.
Opons available to you if you have a disability
You may:
sign the applicaon yourself,
make your mark, or
ask another person to sign for you in your presence
(have the person sign their own name as well.)
If you have adopted the use of a signature stamp for all
purposes of signature, you may use your signature
stamp or ask another person to use your signature
stamp in your presence. (See Minnesota Statutes,
secon 645.44, subdivision 14. )
Informaon regarding Power of Aorney
Voting is not covered by power of attorney. A power of
attorney pertains only to affairs affecting property. A per-
son with power of attorney may only sign for you in your
presence, as outlined above. (See Minnesota Statutes,
secon 523.24, subdivision 14.)
Revised 12-07-2020
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Form 1.: 2021 Minnesota Absentee Ballot Application (Hennepin County)

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Completed 24 December 2020

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