Address Where Voter Lives
2
Voter Information
1
Last Name First Name
Middle (name or initial) Sux (Jr, III, if any)
Date of Birth (mm/dd/yyyy)
Phone Number(s)
Email Address
/ /
The Voter Requests an Early
Voting Ballot for the Following
Election(s)
4
Statewide Primary Election Special Election on June 28, 2022
Send Voter’s Ballot To
(If dierent from voter’s
residential address)
3
Nebraska Secretary of State
Nebraska Early Voting Ballot Application—Special Election
Applications must be physically signed. You can take a picture or scan your request and email it to your county election
ocial. You can also mail or fax your application to your county election oce.
You can start requesting a ballot 120 days before any election. You must submit your application to have a ballot mailed to
you by the close of business on the second Friday before the election. If you have any questions please contact your county
election ocial. You can nd contact information for your county election ocial is on:
sos.nebraska.gov/elections/election-ocials-contact-information
Check the status of your early voting ballot on: ne.gov/go/votercheck
!
WARNING: The penalty for election falsication is imprisonment for up to two years imprisonment and twelve months post-release
supervision, a ne of up to ten thousand dollars, or both.
!
Signature of Person Completing this Form
x
Date
As a voter who is not registered with a recognized political party in Nebraska, I request a
partisan ballot from the following party: (Select only one)
Republican Democratic Libertarian Legal Marijuana NOW
I hereby declare, under penalty of election falsication, that the above information is true.
Printed Name of Agent* (if applicable)
*An agent is a person who requests a ballot for another voter. An agent may request ballots for up to two (2) voters per
election.
Relationship
Street Address
Apartment or Lot (if any)
City, State, ZIP
Same as above OR
Mailing Address
Apartment or Lot (if any)
City, State, ZIP
You cannot use the following section to change or aliate with a political party. You can check whether
you are aliated with a political party online at ne.gov/go/votercheck.
NONPARTISANS ONLY
Any voter who is registered as
Nonpartisan (no party) may request
a ballot for certain oces from any
political party.
If you choose not to request a
partisan ballot, you will be given a
nonpartisan ballot only.
!
!
Nebraska Revised Statute §32-941 Updated April 2022
