Fill - Free fillable Form 2: Voter Registration and Absentee Ballot Request (State Board of Elections) PDF form

Your State may require you to specify a political party to vote in primary elections:

County

Previous name (if applicable)

Identication

Some States require your

full SSN. Check your State’s

pages in the Voting Assistance

Guide on F VA P.go v.

Contact

information

Include international

prexes. No DSN numbers.

Ballot receipt

Last name

First name

Suf x

Apt. #

Legal name

City/Town/Village

Street Address (not P.O. Box)

Voting residence

address

Usually your last U.S.

residence or your legal U.S.

residence. See instructions.

Where to send my

ballot

This is your current mailing

address and should be

different from above. If

required, place a forwarding

address in Box 9.

This information is for of cial use only. Any unauthorized release may be punishable by law. PREVIOUS EDITIONS ARE OBSOLETE.

Please print in black ink.

Classication

Make only 1 selection.

(In most States, you must be

absent from your voting district

to use this form).

I am an activated National Guard member on State orders.

I prefer to receive my ballot, as permitted by my State, by:

I am a member of the Uniformed Services or Merchant Marine on active duty OR

Standard Form 76 (Rev. 08-2013), OMB No. 0704- 0503

Birth date

D D

/ /

M M Y Y Y Y

Additional

requirements

for your State

Such as: mail forwarding

address, additional email

address/phone number,

or other State required

information. See Voting

Assistance Guide.

/ /

You must sign and send in.

Afrmation (REQUIRED): I swear or afrm, under penalty of perjury, that:

• The information on this form is true, accurate, and complete to the best of my

knowledge. I understand that a material misstatement of fact in completion of this

document may constitute grounds for conviction of perjury.

• I am a U.S. citizen, at least 18 years of age (or will be by the day of the election),

eligible to vote in the requested jurisdiction, and

• I am not disqualied to vote due to having been convicted of a felony or other

disqualifying offense, nor have I been adjudicated mentally incompetent; or if so, my

voting rights have been reinstated; and

• I am not registering, requesting a ballot, or voting in any other jurisdiction in the

United States, except the jurisdiction cited in this voting form.

Witness signature / date if required by your State.

Middle name

I am an eligible spouse or dependent.

Email/Online

Telephone

Fax

State

Zip Code

OR Social Security Number

State Driver’s License or ID

Mail Fax

–

Signature

Date

For any questions about this form, consult the Voting

Assistance Guide available in hard copy or on

F VA P. go v or your Voting Assistance Ofcer.

Race

I am a U.S. citizen residing outside the United States, and my return is not certain.

I am a U.S. citizen residing outside the United States, and I intend to return.

I request an absentee ballot for all elections in which I am eligible to vote AND:

I am a U.S. citizen and have never resided in the United States.

Signature

M M

D D Y Y Y Y

Today’s date

Sex

M F

Political party

Rank from 1-3 in order of preference; be sure appropriate contact information is provided above.

For absent Uniformed Service members, their families, and citizens residing outside the U.S.

Voter Registration and Absentee Ballot Request

Federal Post Card Application (FPCA)

See instructions

–

Instructions for Federal Post Card Application

Voter Registration and Absentee Ballot Request

The gray numbers and instructions below correspond to the gray numbered boxes on the face of the form.

 Theclassicationyouchoosemaydetermineinwhichelection(s)youwillbeallowedtovote.Choosethe

one that best represents your current situation.

 Ifyouwanttovoteinprimaryelections,mostStatesrequireyoutospecifyapoliticalparty.Checkyour

State’spagesintheVotingAssistanceGuideonFVAP.govtoseeifyourStaterequiresyoutospecifya

political party.

The information you enter for your name should match the information you normally put on legal or

ofcialforms.Forexample,itshouldbethesamenamethatappearsonyourDriver’sLicenseorother

government-issuedID.

While mostStatesallowyoutoentereitheryourDriver’sLicensenumberorthelast4digitsofyourSocial

SecurityNumber,somewillinvalidatethisformwithoutyourfullSSN.CheckyourState’spagesinthe

VotingAssistanceGuideonFVAP.govtoseeifyourStaterequiresthefullSSN.Also,manyStatesaskthat

youprovideyourraceorethnicgroupinordertodemonstratethattheyarecomplyingwiththeVotingRights

ActandtheNationalVoterRegistrationAct.

 Iftherearequestionsorproblemswithyourform,localelectionofcialswillusethisinformationtocontact

you.Anemailaddressisthesimplestandfastestwayforthemtodoso.Yourvotingmaterialswillbesentto

theemailaddressthatyouprovidehereifyourequestitandyourStateallowsit.Includeanalternateemail

or phone number in Box 9 if necessary.

 Indicateyourpreferredmethodforreceivingyourballotbyrankingeachbox1,2,or3.AllStatesand

jurisdictionsmustsendabsenteeballotstomilitaryandoverseasvotersbyatleastoneofthefollowing:

email,onlinedownload,orfaxifrequested.CheckyourState’spagesintheVotingAssistanceGuideon

FVAP.govtolearnwhatyourStateallows.Youcanalwaysgetyourabsenteeballotbymail.

Thisdeterminesthejurisdictionwhereyouvote.FormilitaryvotersthevotingaddressisyourlegalU.S.

residence.ForoverseascitizensthisisusuallytheU.S.addresswhereyoulastlived.Youdonotneedto

haveanycurrentphysicaltiestothisaddress. Donotuseapostofceboxnumber.Iftheareahasnostreet

names,entertheroutenumberandboxnumber.

 Entertheaddresswhereyouwantvotingmaterialstobesent.Votingmaterialswillbesenttothisaddress

unless you enter a forwarding address in Box 9.

 Enteranythingherethatwouldhelpensurethatyourballotisaccepted.CheckyourState’spagesinthe

VotingAssistanceGuideonFVAP.govforanythingyourStatemayspecicallyrequirehere.Forexample,

someStatesrequirelastdateofresidencyintheU.S.,previouslocationofregistration,overseasemployer,

orwitnessaddress.Ifyouwantyourvotingmaterialstobesentsomewhereotherthanwhereyoulivenow,

enterthatalternate(forwarding)addresshere.Provideanalternateemailaddressandphonenumberhere.

AfrmationReadthiscarefully.Itiswhatyouareagreeingtounderoathandpenaltyofperjurybyllingoutand

sendinginthisform.SomeStatesrequirethatyourformbewitnessed.ChecktheVotingAssistanceGuide

onFVAP.govforyourState’srequirements.

From

(Yournameandcurrentcompletemilitaryoroverseasmailingaddress)

(YourlocalelectionofceintheUnitedStates.CheckyourState’spagesintheVoting

AssistanceGuideonFVAP.govforcontactinformation.)

International airmail postage is required if not mailed in the

U.S.PostalSer vice,APO/FPOsystem,ordiplomaticpouch.

U.S.PostagePaid

39USC3406

OFFICIALABSENTEEBALLOTINGMATERIAL–FIRSTCLASSMAIL

PARAVION

NOPOSTAGENECESSARYINTHEU.S.MAIL–DMM703.8.0

PrivacyActStatement

Authority:Theauthorit ytocollectyourpersonalinformationonthis

formcomesfrom42USC1973f f,“UniformedandOverseasCitizens

AbsenteeVotingAct(UOCAVA).”

PrincipalPurpose:Thisformservesasanapplicationforregistration

and/orrequestforabsenteeballotforallpersonscoveredby

UOCAVA.

RoutineUse(s):Thereisnoretentionofthisinformationbythe

Federalgovernment.Completedformsaresentbyyoutoan

appropriateStateelectionofcial.

Disclosure:Yourdisclosureofpersonalinformationisvoluntary.

However,failuretoprovidetherequestedpersonalinformationmay

keepthepertinentjurisdictionfromprocessingthisrequestandmay

preventyoufromvotingabsentee.

Foranyquestionsaboutthisform,consultthe Voting

AssistanceGuideavailableinhardcopyoron

F VA P. go v oryourVotingAssistanceOfcer.

StandardForm76(Rev.08 -2013)

AgencyDisclosureStatement

The public reporting burden for this collection of information is

estimatedtoaverage15minutesperresponse,includingthetime

forreviewinginstructions,gatheringandmaintainingthedata

needed,andcompletingandreviewingthecollectionofinformation.

Sendcommentsregardingthisburdenestimateoranyother

aspectofthiscollectionofinformation,includingsuggestionsfor

reducingtheburden,totheDepartmentofDefense,Washington

HeadquartersServices,ExecutiveServicesDirectorate,Information

ManagementDivision,4800MarkCenterDrive,EastTower,Suite

02G09,Alexandria,VA22350 -3100.[OMBCONTROL#0704-0503].

Respondents should be aware that notwithstanding any other

provisionoflaw,nopersonshallbesubjecttoanypenalt yforfailingto

comply with a collection of information if it does not display a currently

validOMBcontrolnumber.PLEASEDONOTRETURNYOUR

COMPLETEDFORMTOTHEADDRESSABOVE.

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Form 2: Voter Registration and Absentee Ballot Request (State Board of Elections)

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