Fillable Form 2: Pennsylvania Application for Absentee Ballot A (Pennsylvania)

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Form 2: Pennsylvania Application for Absentee Ballot A (Pennsylvania)

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The Form 2: Pennsylvania Application for Absentee Ballot A (Pennsylvania) form is 2 pages long and contains:

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  • 5 check-boxes
  • 40 other fields

Country of origin: US
File type: PDF

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Page 1
Pennsylvania Application for Absentee Ballot
Use black ink
Print your name
Please print your name
exactly as registered.
1
Last name
First name
Jr Sr II Ill IV
Middle name or initial
About you
Phone and email are optional
and used if information is
missing on this form.
2
Birth date
Phone
Occupation
Email
Your address
Please print your address
exactly as registered.
3
Address (not P.O. Box) Apt. number
City/Town State
PA
Zip Code
Municipality County
Ward (if known) Voting district (if known)
I have lived at this address since:
Are you a State or Federal Government employee?
Yes No
Where to mail
ballot?
4
Same as above Address or P.O. Box
City/Town State Zip code
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 “Necessary Identication”
on Page 3.
5
PA driver's license or PennDOT ID card number
Last four digits of your Social Security number X X X - X X -
I do not have a PA driver’s license or a PennDOT ID card or a Social Security number.
Reason
Select a reason for applying for
an absentee ballot.
6
I hereby apply for an absentee ballot for the following reason:
I will be absent from my municipality (Complete section A)
I have an illness or physical disability (Complete section B)
Section A –
Absence from
municipality
A
I declare that I am eligible to vote absentee at the forthcoming primary or election since I expect that my duties, occupation
or business will require me to be absent from the municipality of my residence on the day of the primary or election for the
reason stated below; and that all of the information which I have listed on this absentee ballot application is true and correct.
Reason for absence Date
VOTER SIGNATURE HERE X
Section B –
Illness/Physical
disability
B1
I declare that I am eligible to vote absentee at the forthcoming primary or election due to the illness or physical disability
stated below; that the information required to be listed pertaining to my attending physician is correctly stated herein; and that
all other information which I have listed on this absentee ballot application is true and correct.
Nature of illness or physical disability Date
Physician name Physician phone
Physician ofce address
VOTER SIGNATURE HERE X
Help with this form
Complete this section if you
are unable to sign in Section
B1 because of illness or
physical disability.
See “Assistance in voting” on
Page 3 for more information.
B2
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. I have made, or have received assistance in making my mark in lieu of my signature.
Mark of voter X Date
Address of witness
Signature of witness X
WARNING: If you receive an absentee 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 absentee ballot by the deadline, you may only vote a provisional ballot at your polling place on election day, unless you surrender your absentee ballot and
envelope to the judge of elections to be voided to vote by regular ballot.
continued on next page...
A
DOS-08/2020
Page 2
DOS-08/2020
Section C (Optional): Annual Absentee Ballot Request Because of
Permanent Illness or Permanent Disability and Physician’s Certification
(to be completed with your Physician below)
• If you are a voter with a permanent illness or a permanent disability, you may request to be placed on an annual absentee ballot
list. See “What is an annual absentee ballot request?” on Page 3.
• You need only le a physician’s certicate of permanent illness or permanent disability once. Once your disability status has been
certied by your physician, your physician will not need to recertify your disability status, and you will be placed on the annual
absentee voter list.
• If you are approved as an annual absentee voter, you will recieve an application to renew your request for absentee ballots each year.
• If you lose your disability status, you must inform your county board of elections.
Annual absentee
request
See “What is an annual absentee
ballot request?” for more
information.
C1
If you would like to receive absentee ballots for the remainder of this year and if you would like to automatically
receive an annual application to automatically receive absentee ballots each year, please indicate below.
I would like to receive absentee ballots this year and receive annual applications for absentee ballots
each year.
(Please have your physician sign the certication in Section C2.)
Certicate of
permanent illness
or permanent
physical disability
Have your physician sign this
certication if you indicated
you would like to be an annual
absentee voter in section C1.
C2
I hereby certify that the above named voter is permanently disabled, and either physically unable to attend
the polls or physically unable both to operate a voting machine (or mark the ballot) and to orally request
assistance to do so.
Signature of physician X
Print physician name
Date
WARNING: If you receive an absentee 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 absentee ballot
by the deadline, you may only vote a provisional ballot at your polling place on election day, unless
you surrender your absentee ballot and envelope to the judge of elections to be voided to vote by
regular ballot.
Page 3
Once your application is completed, you may return it to your local county board of elections. If you’re
unsure of where to mail your application, please visit www.VotesPA.com/county for more information.
How to submit your application:
In order to apply for an absentee ballot, you must supply your PA Driver’s License or PennDOT issued photo ID
card number in the Identification 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 identification, 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 Identification section. If you
choose this option, you must enclose a photocopy of an acceptable ID.
Please visit www.VotesPA.com/MailBallot for more information, call 1-877-VotesPA (1-877-868-3772), or
contact your county board of elections.
Necessary identification:
If you have a permanent illness or a permanent disability you may be added to the annual absentee request
list. Once your physician signs the certification of permanent disability and your request is approved, you will
automatically receive ballots for the remainder of the year, and you will receive an application to renew your
request for absentee ballots each year.
What is an annual absentee ballot request?
The deadline to apply for a civilian absentee ballot
is 5:00PM on the Tuesday before the election. Please
note your application must be received in the county
board of election’s office 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 in the county board of
election’s office by that time. Postmarks do not count.
Deadline alert:
Questions?
Call your County
Election Office
or call 1-877-VOTESPA
(1-877-868-3772).
For more information about
voting, visit our website:
www.VotesPA.com.
Información en español:
Si le interesa obtener este formulario en
español, llame al 1-877-868-3772.
Pennsylvania Application for Absentee Ballot
If you require assistance with completing your ballot due to a disability, you must also complete a Statement of
Absentee Elector Requiring Assistance form. Please visit www.VotesPA.com for more information.
Assistance in voting:
WARNING: If you receive an absentee 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 absentee
ballot by the deadline, you may only vote a provisional ballot at your polling place on election day,
unless you surrender your absentee ballot and envelope to the judge of elections to be voided to
vote by regular ballot.
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Form 2: Pennsylvania Application for Absentee Ballot A (Pennsylvania)

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Completed 18 January 2021

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