EL-121 | Rev 2020-06| Wisconsin Elections Commission, P.O. Box 7984, Madison, WI 53707-7984 | 608-266-8005 | web: elections.wi.gov | email: elections@wi.gov
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Wisconsin Application for Absentee Ballot
(Municipal Clerk) If in-person
voter, check here:
Absentee ballots ma
also be requested at M
Vote.wi.
ov
Confidential Elector ID#
(HINDI - sequential #) (Official Use Only)
WisVote ID #
(Official Use Only)
Ward No.
Detailed instructions for completion are on the back of this form. Return this form to your municipal clerk when completed.
You must be registered to vote before you can receive an absentee ballot. You can confirm
your voter registration at https://myvote.wi.gov
PHOTO ID REQUIRED, unless you qualify for an exception. See instructions on back for exceptions.
VOTER INFORMATION
1
Municipality County
2
Last Name
First Name
Middle Name
Suffix
(e.g. Jr, II, etc.)
Date of Birth
(MM/DD/YYYY)
Phone
Fax
Email
3
Residence Address: Street Number & Name
Apt. Number
City
State & ZIP
4
Fill in the appropriate circle – if applicable (see instructions for definitions): Military Permanent Overseas Temporary Overseas
I PREFER TO RECEIVE MY ABSENTEE BALLOT BY:
(Ballot will be mailed to the address above if no preference is indicat
ed.
Absentee ballots may not be forwarded.)
5
MAIL
Mailing Address: Street Number & Name
VOTE IN
CLERK’S
OFFICE
Apt. Number
City
State & ZIP
Care Facility Name (if applicable)
C / O (if applicable)
FAX
Fax Number
Voter must have a computer and printer when
receiving a ballot by fax or email. Voted ballots
must be returned by mai
l.
EMAIL
Email Address
I REQUEST AN ABSENTEE BALLOT BE SENT TO ME FOR:
(mark only one)
6
The election(s) on the following date(s): ____________________________________________________________________________
All elections from today’s date through the end of the current calendar year (ending 1
2/31).
For indefinitely-confined voters only: I certify that I am indefinitely confined because of age, illness, infirmity or disability and
request absentee ballots be sent to me automatically until I am no longer confined, or I fail to return a ballot. Anyone who makes false
statements in order to obtain an absentee ballot may be fined not more than $1,000 or imprisoned not more than 6 months or both.
Wis. Stats. §§ 12.13(3)(i), 12.60(1)(b).
TEMPORARILY HOSPITALIZED VOTERS ONLY
(please fill in circle)
7
I certify that I cannot appear at the polling place on election day because I am hospitalized, and appoint the following person to serve as
my agent, pursuant to Wis. Stat. § 6.86(3).
Agent
Last Name
Agent
First
Name Agent
Middle
Name
AGENT: I certify that I am the duly appointed agent of the hospitalized absentee elector, that the absentee ballot to be received by me is
received solely for the benefit of the above named hospitalized elector, and that such ballot will be promptly transmitted by me to that elector
and then returned to the municipal clerk or the proper polling place.
Agent
Signature
X
Agent
Address
ASSISTANT DECLARATION / CERTIFICATION
(if required)
I certify that the application is made on request and by authorization of the named elector, who is unable to sign the application due to physical disability.
Agent
Signature
X
Today’s Date
VOTER DECLARATION / CERTIFICATION
(required for all voters)
I certify tha
t I am a qualified elector, a U.S. Citizen, at least 18 years old, having resided at the above residential address for at least 28 consecutive days
immediately preceding this election, not currently serving a sentence including probation or parole for a felony conviction, and not otherwise disqualified
from voting. Please sign below to acknowledge that you have read and understand the above.
Voter
Signature
X
Today’s Date
Instructions
Town
Village
City
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Military and overseas only
Military and overseas only
