Use black ink
DOS 08/2020
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
2
Birth date (MM/DD/YYYY) Occupation
Your address
Please print your address
exactly as registered.
3
Address (not P.O. Box) Apt. number
City/Town State 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
Want your ballot
mailed?
Due to mail processing times,
please consider picking up
and delivering your ballot
in-person.
4
Same as above Address or P.O. Box
City/Town State Zip code
Identication
If you have a PennDOT number,
you must use it. If not, please
provide the last four digits of
your Social Security number.
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 emergency absentee ballot
and describe the circumstances
for applying.
6
I hereby apply for an emergency absentee ballot for the reason checked below. (please check one reason
below)
I have or had an illness or physical disability that prevented me from applying for a non-emergency
absentee ballot prior to the application deadline.
I was unable to apply for a non-emergency absentee ballot or mail-in ballot by the deadline due to my
business, duties, or occupation.
I became physically ill or disabled after the deadline to submit an application for a non-emergency
absentee ballot.
I expect to be absent from my municipality on election day and I did not know that I would be absent
prior to the application deadline for a non-emergency absentee ballot.
Describe the circumstances that prevented you from applying for a non-emergency absentee ballot before
the deadline or that will prevent you from appearing at the polling place on election day:
I hereby declare that the information I have provided on this emergency absentee ballot application is true
and correct and is made subject to the penalties under 18 Pa.C.S. § 4904 (relating to unsworn falsication
to authorities).
Voter signature here X Date
Help with this form
Complete this section if you
are unable to sign the
declaration in Section 6.
7
I hereby state that I am unable to sign my application for an emergency 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
Pennsylvania Application for Emergency Absentee Ballot
IMPORTANT: 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.
