Fillable Form 1: Fulton County Absentee Ballot Application (County of Fulton)

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Form 1: Fulton County Absentee Ballot Application (County of Fulton)

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8.
Fulton County Absentee Ballot Application
2714 State Highway 29, Suite 1 Johnstown, N.Y. 12095 518-736-5530/5531 Fax:736-1612
Please print clearly. See detailed instructions on the back of this form.
This application must either be personally delivered to your county board of elections not
later than the day before the election, or postmarked by a governmental postal service
not later than 7th day before Election Day. The ballot itself must either be personally delivered
to the board of elections no later than the close of polls on Election Day, or
postmarked by a
governmental postal service not later than the day before the election and
received no later than the
7th day after the election.
BOARD USE ONLY:
Town/City/Ward/Dist:
Registration No:
Party:
voted in office took
1
Absence from county on Election Day
Absence begins: ___________Absence ends:___________
Temporary illness or physical disability
Permanent illness or physical disability
Duties related to primary care of one or more
individuals who are ill or physically disabled
2.
Absentee ballot(s) requested for the following election(s) :
College/Vacation/Work out of Town
Patient or inmate in a Veterans’ Administration Hospital
Detention in jail/prison, awaiting trial, awaiting action by a
grand jury, or in prison for a conviction of a crime or offense
which was not a felony
Primary Election only General Election only Special Election only
last name or surname first name
3
Middle initial
date of birth
4
/
/
county where you live phone number (optional)
address where you live (residence) street
apt city
state
zip code
5
NY
6
Delivery of Primary Election Ballot (check one) Deliver to me in person at the board of elections
I authorize (give name): to pick up my ballot at the board of elections.
Mail ballot to me at: (mailing address)
street no. street name apt. city state zip code
7
Delivery of General (or Special) Election Ballot (check one) Deliver to me in person at the board of elections
I authorize (give name): to pick up my ballot at the board of elections.
Mail ballot to me at: (mailing address)
street no. street name apt. city state zip code
Applicant Must Sign Below
I certify that I am a qualified and a registered (and for primary, enrolled) voter; and that the information in this application is
true and correct and that this application will be accepted for all purposes as the equivalent of an affidavit and, if it contains a
material false statement, shall subject me to the same penalties as if I had been duly sworn.
Sign Here: X
Date
/
/
If applicant is unable to sign because of illness, physical disability or inability to read, the following statement must be
executed: By my mark, duly witnessed hereunder, 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 or because I am unable
to read. I have made, or have the assistance in making, my mark in lieu
of my
signature. (No power of attorney or
preprinted name stamps allowed. See detailed instructions.)
Date
/
/_
Name
of
Voter:_
Mark:_
Board Use Only
I, the undersigned, hereby certify that the above named voter affixed his or her mark to this application in my presence and I know him
or her to be the person who affixed his or her mark to said application and understand that this statement will be accepted for all
purposes as the equivalent of an affidavit and if it contains a material false statement, shall subject me to the same penalties as if I had
been duly sworn.
Signature of Witness to Mark Address of Witness to Mark
Instructions:
Who may apply for an absentee ballot?
Each person must apply for themselves. It is a felony to make a false statement in an application
for an absentee ballot, to attempt to cast an illegal ballot, or to help anyone to cast an illegal ballot.
Information for military and overseas voters:
If you are applying for an absentee ballot because you or your family are in the military or because
you currently reside overseas, do not use this application. You are entitled to special provisions if
you apply using the Federal Postcard Application. For more information about military/overseas
voting, contact your local board of elections or refer to the Military and Federal Voting sections at:
http://www.elections.state.ny.us/Voting.html
Where and when to return your application:
Applications must be mailed seven days before the election, or hand-delivered to your county
board of elections by the day before the election. If the address of your county board of elections
is not provided on this form, contact information for your local election office can be found on the
New York State Board of Elections’ website, under “County Boards of
Election”
directory”
at:
http://www.elections.state.ny.us/CountyBoards.html
Options available to you if you have an illness or disability:
If you check the box indicating your illness or disability is permanent, once your application is ap-
proved you
will
automatically
receive a ballot for each election in which you are eligible to vote,
without having to apply again. You may sign the absentee ballot application yourself, or you may
make your mark and have your mark witnessed in the spaces provided on the bottom of the appli-
cation. Please note that a power of attorney or printed name stamp is not allowed for any voting
purpose.
When your ballot will be sent:
Your absentee ballot materials will be sent to you at least 32 days before federal, state, county, city
or town elections in which you are eligible to vote. If you applied after this date, your ballot will be
sent immediately after your completed and signed application is received and processed by your
local board of elections. If you provide dates in section 2, identifying the time frame within which
you will be absent from your county or from the City of New York, you will be sent a ballot for any
primary, general, special election or presidential primary election which might occur during the
time frame you have specified. If you prefer, you may designate someone to pick up your ballot for
you, by completing the required information in section 6 and/or section 7, as appropriate. Contact
your local county board of elections if you have not received your ballot.
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Form 1: Fulton County Absentee Ballot Application (County of Fulton)

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Completed 6 August 2020

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