Application for State Election Absentee Ballot-RSA 657:4
Absence, Religious Observance, and Disability
(Uniformed and Overseas Citizen Voters Residing Outside the U.S. use the federal post card application)
Voter Not
I. I hereby declare that (check one):
I am a duly qualified voter who is currently registered to vote in this town/ward.
I am absent from the town/city where I am domiciled and will be until after the next
election, or I am unable to register in person due to a disability, and request that the forms
necessary for absentee voter registration be sent to me with the absentee ballot.
II. I will be entitled to vote by absentee ballot because (check one):
I plan to be absent on the day of the election from the city, town, or unincorporated place
where I am domiciled.
I am requesting a ballot for the presidential primary election and I may be absent on the
day of the election from the city, town, or unincorporated place where I am domiciled, but
the date of the election has not been announced. I understand that I may only make such a
request 14 days after the filing period for candidates has closed, and that if I will not be
absent on the date of the election I am not eligible to vote by absentee ballot.
I cannot appear in public on election day because of observance of a religious
I am unable to vote in person due to a disability.
I cannot appear at any time during polling hours at my polling place because of an
employment obligation. For the purposes of this application, the term “employment” shall
include the care of children and infirm adults, with or without compensation.
For use only on the Monday immediately prior to the election: I cannot appear at my
polling place on election day because the National Weather Service has issued a winter storm
warning, blizzard warning, or ice storm warning for election day applicable to my city, town,
or unincorporated place and either (check one):
I am elderly or infirm or I have a physical disability, and would otherwise vote in
person but I have concerns for my safety traveling in the storm.
I anticipate that school, child care,
or adult care will be canceled, and would
otherwise vote in person but will need to care for children or infirm adults.
Any person who votes or attempts to vote using an absentee ballot who is not entitled to
vote by absentee ballot shall be guilty of a misdemeanor. RSA 657:24
III. I am requesting an official absentee ballot for the following election (check only
*Required for Primary Elections: I am a member of, or I am now declaring my
affiliation with a party and I am requesting a ballot for that party’s primary (check
only one):
*State Primary Election to be held on September 8, 2020.
Democratic Party
Republican Party
State General Election to be held on November 3, 2020
Turn Over – You Must Complete the Page 2
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Date Returned:
_ _/_ _/_ _ _ _
Date Mailed:
_ _/_ _/_ _ _ _
Voter ID #
__ __ __ __ __ __ __ __ __
Last Name:____________________
First Name:____________________
Date Requested:
_ _/_ _/_ _ _ _
IV. Applicant’s Name (Please Print):
Last Name First Name Middle Name (Jr., Sr., II,III)
Applicant’s Voting Domicile (home) Address:
Street Number Street Name Apt/Unit City/Town Ward Zip Code
Mail the ballot to me at this address (if different than the above home address)
Street or PO Box # Street name Apt/Unit City/Town State Zip Code
Applicant’s Phone Number: (_____) ______ - _____________
(Cell phone or number where you can be contacted prior to and on election day is
Applicant’s Email Address: ______________________@__________
Applicant’s Signature: _____________________________Date Signed: _______________
The applicant must sign this form to receive an absentee ballot. Any person who witnesses
and assists a voter with a disability in executing this form shall print and sign his or her
name in the space provided on the application form.
I attest that I assisted the applicant in executing this form because he/she has a disability.
Signature ________________________Print Name ________________________________
Mail/fax/email or hand deliver this completed form to your local City/Town Clerk.
For local clerk addresses and fax numbers:
– Click on “Clerk
Information Search” tab.
Visit the web site:
to track your absentee
ballot. You may verify receipt of your application, obtain the date when your absentee ballot
was mailed to you, the date the clerk receives your completed absentee ballot, and after the
election learn if your absentee ballot was rejected/not counted and why. Contact your clerk
if you have questions regarding the information on the “Voter Information Look-up /
Absentee Ballot Search” site.
For Official Use Only:
Voter Verified
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