BOARD USE ONLY:
Town/City/Ward/Dist:
Registration No:
Party:
voted in oce
New York State Absentee Ballot Application
Please Print Clearly. See detailed instructions.
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.
3.
last name or surname rst name middle initial sux
5.
address where you live (residence) street apt city state zip code
NY
Erie County Board of Elections
134 West Eagle Street
Bualo, NY 14202
Mail or deliver to:
4.
date of birth
_____/_____/______
county where live
ERIE
phone number email address
1.
I am requesng, in good faith, an absentee ballot due to (check one reason):
absence from Erie County on Election Day
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
resident or patient of a Veterans’ Health Administration
hospital
detention in jail/prison, awaiting trial, awaiting action by
a grand jury, or in prison for conviction of a crime or
oense which was not a felony
6.
I authorize (given name):_____________________________to pick up my ballot at the Board of Elections
Mail ballot to me at: (mailing address)
Deliver to me in-person at the Board of Elections
Delivery of Primary Election Ballot (check one)
street no. street name apt. city state zip code
Applicant Must Sign below
2.
Primary Elecon only
Any election held between these dates:
Special Elecon onlyGeneral Elecon only
absence begins:_____/_____/20____ absence ends:_____/_____/20____
absentee ballot(s) requested for the following election(s):
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 ____/____/20___ Name of Voter:__________________________________ Mark:__________________
I, the undersigned, hereby certify that the above named voter axed his or her mark to this application in my
presence and I know him or her to be the person who axed his or her mark to said application and understand
that this statement will be accepted for all purposes as the equivalent of an adavit and if it contains a material
false statement, shall subject me to the same penalties as if I had been duly sworn.
8.
I certify that I am qualied 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 adavit 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_____/_____/20_____
Board Use Only
2010 ABS Application rev (4/2/2018)
(address of witness to mark)
(signature of witness to mark)(name of witness to mark)
7.
I authorize (given name):_____________________________to pick up my ballot at the Board of Elections
Mail ballot to me at: (mailing address)
Deliver to me in-person at the Board of Elections
Delivery of General (or Special) Election Ballot (check one)
street no. street name apt. city state zip code
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