Fillable Form 3: Application for Georgia Ocial Absentee Ballot (City of Oakland)

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Form 3: Application for Georgia Ocial Absentee Ballot (City of Oakland)

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The Form 3: Application for Georgia Ocial Absentee Ballot (City of Oakland) form is 2 pages long and contains:

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  • 14 check-boxes
  • 33 other fields

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File type: PDF

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Please print clearly. Be sure to complete all required sections.
Brad Raffensperger
Secretary of State
The information provided in this document is made under oath and penalty of law and will be used for ocial
government purposes. When you sign this application, you arm that you are a citizen of the U.S.,
currently reside in Georgia and are eligible to vote in Georgia. Giving false information on this application
violates Georgia law and is punishable by a ne up to $100,000, imprisonment for up to 10 years, or both.
Your name as it appears on your voter registration.
The residential or mailing address on your voter registration. If you no longer reside at the address where you
are registered to vote, contact your county election oce prior to submitting this application.
The application must be received by your election oce* 11 days before the election.
Application for Georgia Ocial Absentee Ballot
2
6
1
Print your name
Required
Contact information
Recommended
Date of Election
Required
Last
Date of Primary, Election, or Runoff (mm/dd/yyyy)
Sux
First
Phone number
Middle
Email address
7
Voter identication
Required
Print carefully. This
information will be used
to verify your identity.
Failure to provide
accurate information
may delay processing
your application.
You must provide your
date of birth AND
• a Georgia
Driver’s License
or Identication
Card number
OR
• a copy of an
acceptable
identication
from the list in
the instructions.
4
5
Residential address
Required Your ballot will be
sent here unless you provide
a temporary mailing address.
Temporary ballot
mailing address
Only if you are temporarily
living outside the county**
and want your ballot
sent to this address.
Address
City GA ZipCounty
If you received this application with your information pre-lled, received multiple or duplicate copies in the mail, or if an unauthorized person
offers to return your absentee ballot application, please report this to reportfraud@sos.ga.gov.
8
Voter oath and
signature
Required
Use a pen. No electronic
signatures allowed.
I, the undersigned, do swear and arm that I am eligible to vote in Georgia, am a citizen of the U.S. and the facts
presented in this application are true. By signing this oath, you are swearing that you are the voter requesting an
absentee ballot.
Signing this oath on behalf of another voter violates Georgia law and is punishable by a ne up to
$100,000, imprisonment for up to 10 years, or both.
Voter, sign and date here (Required)
Form continues ►
X
Instructions:
• Make sure your identication on your
ID card or document is visible.
• Take a photo of your full completed
application and submit it
electronically to your elections oce*
(addresses are online: elections.sos.
ga.gov/Elections/countyregistrars.
do). You may also submit a hard copy
of your application via U.S. mail or in
person to your elections oce*.
• If your acceptable form of
identication does not t in this box,
please attach a copy and submit it
with your application.
Date of birth (mm/dd/yyyy)
This address must be in a different county** than the one where you are registered unless you are physically
disabled or detained in jail or other detention facility.
Address
City ZipState
Georgia Driver’s License Number or State Identication Card Number
I do not have a Georgia Driver’s License or Identication Card
and I am providing a copy of acceptable identication below.
Place identication here
if you did not provide a Georgia
driver’s license or ID number
OR
Date (mm/dd/yyyy)
AND
APP-21
3
Type of ballot
Required in primary
Democratic Republican Non Partisan (will not have ANY party candidates listed)
06/21/2022
NOTE: Applications will be accepted between April 4th through June 10th for the 06/21/2022 General Primary R
unoff
Reg # _______________
__________
Brad Raffensperger
Secretary of State
Ballot to be:
Application for Georgia Ocial Absentee Ballot
11
Requesting a ballot
on behalf of a voter?
If yes, complete this section.
The voter must be physically
disabled or temporarily
residing out of the county**
and must still be eligible to
vote in the county** where
he or she is registered.
Relationship to voter
Dist. Combo
Accepted
GA DL
Precinct
Issued
Other
Ballot #
Pack
Rejected
Review
Email
12
Ballot request
opt-in
Optional
If you meet the eligibility
criteria, you may opt-in to
receive an absentee ballot
for the rest of the elections
cycle without making
another application.
10
Assisting a voter?
If yes, the assistant must
complete this section. Voter
assistance is only allowed
if the voter is illiterate
or physically disabled.
I opt-in to receive an absentee ballot for
the rest of the election cycle.
physically disabled
temporarily residing out of the county**
is eligible
is not eligible
D- Disabled. I am physically disabled
E- Elderly. I am 65 years of age or older
U- UOCAVA. I am a uniformed service
member, spouse or dependent of a
uniformed service member, or other US
citizen residing overseas. (Complete the
information to the right)
MOS - Military Overseas
MST - Military Stateside
OST - Overseas Temporary Resident
OSP - Overseas Permanent Resident
(may vote for federal oces only)
Mailed
electronically
Delivered to voter in hospital
by Registrars or Deputy
Voted in oce
(municipal only)
Acceptable forms of identication if you
do not have a Georgia Driver’s License or
State Identication Card Number
Identication with your photograph:
• United States military identication card
• Employee identication card issued by any branch, department,
agency, or entity of the United States government, Georgia state
government, or Georgia county, municipality, board, authority, or
any other entity of the state of Georgia
• Georgia voter identication card
• United States Passport
• Tribal identication card
Documents that show your name and address:
• Current utility bill • Paycheck
• Bank statement • Other government document
• Government check
Assistant’s
signature
Date (mm/dd/yyyy)
X
I swear that the facts contained in this application
are true and that I am either the mother, father,
grandparent, brother, sister, aunt, uncle, spouse,
son, daughter, niece, nephew, grandchild,
son-in-law, daughter-in-law, mother-in-law,
father-in-law, brother-in-law or sister-in-law of
the age of 18 and acknowledge that making a
false statement on this application regarding
my relationship to the voter violates Georgia
law and is punishable by a ne up to $1,000,
12 months in jail, or both.
By signing as assisting the voter, you are swearing under oath that the voter is entitled to assistance. Assisting
a voter who is not eligible for assistance in completing this application violates Georgia law and is punishable by
a ne up to $100,000 or imprisonment for up to 10 years, or both.
I swear (or arm) that the above-named voter is:
(check one)
I certify that the above named voter
I am eligible for the reason selected below:
Ballot Dates ID Shown
For oce use only
UOCAVA Voters only
My current status is (check one)
(Optional) By entering my email, I request that my absentee
ballot be transmitted to me electronically.
Assistant’s name
Signature of authorized and eligible requestor
X
Registrar signature
Your name as it appears on your voter registration.
9
Print your name
Required
Last
Sux
First
Middle
How to return your absentee ballot application
Absentee ballot applications must be received 11 days before the date of
the election. You can return the form by:
• Email to Absentee@CobbCounty.org
• Fax to (770) 528-2458 or (770) 528-2519
• Mail to Cobb County Board of Elections & Registration
PO Box 649
Marietta, GA 30061-0649
• In-Person to Cobb County Board of Elections & Registration Office
736 Whitlock Avenue NW, Suite 400
Marietta, GA 30064
No person or entity other than the elector, a relative authorized to request an absentee ballot for such
elector, a person signing as assisting an illiterate or physically disabled elector with his or her application, a
common carrier charged with returning the ballot application, an absentee ballot clerk, a registrar, or a law
enforcement officer in the course of an investigation shall handle or return an elector’s completed absentee
ballot application. Handling a completed absentee ballot application by any person or entity other than as
allowed in this paragraph is a misdemeanor.
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Form 3: Application for Georgia Ocial Absentee Ballot (City of Oakland)

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Completed 23 May 2022

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