APPLICATION FOR ABSENTEE BALLOT (Español en otro lado)
ED-3 Rev. 2/09
You must complete a separate application for each election, primary and referendum.
Instructions: All applicants must fill out sections I, II, III, IV, VI. If someone assists you in completing this
application they must complete section VII. Members of armed forces and electors temporarily living overseas
may also check one choice in section V, if applicable. Return completed application to your municipal clerk.
Section I. – Applicant’s Information
Date of Birth
(Number, Street, Town)
Telephone No. E-mail Address______________________________
Section II. – Delivery of Absentee Ballot
The set of absentee voting forms shall be: (check only one)
□ Given to me personally (You must apply in person; forms will not be mailed to you.)
□ Mailed to me personally at the following address:
(Use only if the mailing address is different from the address above.)
□ Supervised Ballot. Check this box if you live in an institution where supervised balloting will be conducted.
Section III. - Purpose of Application
A. This application is for (check one): □Election □Primary □Referendum
B. Date of Election, Primary or Referendum:
C. For PRIMARY only, specify party in which applicant is eligible to vote:
Section IV. – Statement of Applicant
I the undersigned applicant believe that I am, or will be, eligible to vote at the election, primary or referendum indicated above and
that I expect to be unable to appear at the polling place during the hours of voting for the reason below: (check only one)
□ My active service in the Armed Forces of the United States
□ My absence from the town during all of the hours of voting
□ My illness
□ My religious tenets forbid secular activity on the day of the election, primary or referendum
□ My duties as a primary, election or referendum official at a polling place other than my own during all of the hours of voting
□ My physical disability
Section V. (This section to be used by Members of the Armed Forces and Electors Temporarily Residing Overseas only):
□ I am a member of the armed forces or the spouse or dependent living where such member is stationed who due to military
contingencies needs additional time to vote by absentee ballot. I therefore request that a blank absentee ballot be issued to me
beginning 90 days before the regular election. I understand that if the military contingency ceases to exist, I may apply for an
additional ballot with candidates printed on it.
□ I am an elector of the above municipality who is (1) temporarily living or expects to be living or traveling outside the territorial
limits of the United States before and on election day or (2) a member of the armed forces or the spouse or dependent living where
such member is stationed, and request that a blank absentee ballot, together with a complete list of candidates and questions be issued
to me (approximately 45 days before an election and 30 days before a primary). If this application reaches the municipal clerk after
the time of availability of regular absentee ballots, I understand that I will be sent a regular ballot with candidates printed on it.
Section VI. – Applicant’s Declaration
I declare, under the penalties of false statement in absentee balloting, that the above statements are true and correct, and that I am the
applicant named above.
(Sign your legal name in full. If you are unable to write, you may authorize some one to write your name and the date in the spaces
provided, followed by the word “by” and the signature of the authorized person. Such person must also complete section VII below.)
Signature of Applicant: Date Signed:
Section VII. – Declaration of person providing assistance
(Completed by any person who assists with completion of application)
I sign this application under penalties of false statement in absentee balloting.
Printed Name: Tel. No:
Penalties for False Statements
A person is guilty of false statement in absentee balloting when he intentionally makes a false written statement in or on or signs the name of another person to the
application for an absentee ballot or the inner envelope accompanying any such ballot, which he does not believe to be true and which statement or signature is
intended to mislead a public servant in the performance of his official function. False statement in absentee balloting is a class D felony. The sentence for a class D
felony shall be at least one year but may not exceed five years in prison. A fine for the conviction of a class D felony shall not exceed five thousand dollars.
This application is to be returned to municipal clerk of municipality in which you are a registered voter. Absentee ballot sets are to be provided by the municipal clerk
beginning 31 days before an election, 21 days before a primary, or 19 days before a referendum, upon application properly made. Blank ballots may be sent out to
certain military persons beginning 90 days before a regular election and to Connecticut electors temporarily residing outside the U.S. and all military persons beginning
approximately 45 days before a regular election, approximately 30 days before a primary and as soon as a complete list of candidates and questions is available before a
Return this completed application to your municipal clerk. If your municipal clerk has a fax machine, you may fax this application to the clerk but must also mail
this completed application with your original signature to the clerk, either separately or with your absentee ballot. If your application with your original signature
is not received by the close of the polls on the day of the election, primary, or referendum, your absentee ballot will not be counted.
For Municipal Clerk’s Use
Outer Envelope Serial No.
Date Forms Issued
Pol. Subdivision Voting District No.