Fillable Individual with a Disability Application for Electronic Absentee (Cascade County)

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Individual with a Disability Application for Electronic Absentee (Cascade County)

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The Individual with a Disability Application for Electronic Absentee (Cascade County) form is 3 pages long and contains:

  • 1 signature
  • 8 check-boxes
  • 20 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Cascade County

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Individual with a Disability
Application for Electronic Absentee
Ballot
Including Absentee List Request, Election Specific Absentee Ballot
Request and Request for Absentee Ballot Due to Illness or Health
Emergency. Fields marked with an asterisk (*) are required fields.
Please type or use black or blue pen only and print clearly.
COMPLETE FORM AND SUBMIT TO COUNTY ELECTION OFFICE: SEE LIST
OF COUNTY ELECTION OFFICE ADDRESSES AND CONTACT INFO AT
HTTP://SOS.MT.GOV/ELECTIONS/FORMS/ELECTIONS/ELECTIONADMINI
STRATORS.PDF, BY NOON THE DAY BEFORE ELECTION DAY
APPLICANT IDENTIFYING AND CONTACT INFORMATION
Last Name* First Name* Middle Name
Birthdate* (MM/DD/YYYY) Phone Number Email Address
County where you reside and are registered to vote*
Montana Residence Address* City* Zip Code*
Mailing Address (required if differs from residence address*)
City and State Zip Code
Check if the mailing address listed above is for part of the year only
and if so, complete the information below (for absentee ballot list only).
Clearly print the complete mailing address(es) and specify the applicable
time periods for address (add more addresses as necessary).
Seasonal Mailing Address City and State Zip Code
Period (mm/dd/yyyy-mm/dd/yyyy)
BALLOT REQUEST OPTIONS AND VOTER AFFIRMATION
I request an absentee ballot to be emailed to me for ALL elections in
which I am eligible to vote as long as I remain qualified to receive an
electronic ballot as an individual with a disability. I understand that in
order to continue to receive an electronic absentee ballot, I must
complete, sign, and return a confirmation notice mailed to me by the
county election office;
OR
I hereby request an absentee ballot for the upcoming election (check
only one):
Primary General Municipal
Other election to be held on
By signing below, I understand that I am officially requesting an
absentee ballot, and affirm that I am eligible to receive and vote an
electronic ballot because I am an individual with a temporary or
permanent physical impairment such as impaired vision, impaired
hearing or impaired mobility in accordance with 13-3-202, Montana
Code Annotated, and I will have met the 30-day Montana residency
requirement before voting my absentee ballot. (Also sign affidavit at
bottom of page if requesting due to illness or health emergency.)
____________________________________ _______________
*Signature of Elector – *Date Signed
If elector is unable to sign, may use fingerprint, mark or Agent
Optional - Voter Information Pamphlet Request (an electronic version of
this pamphlet can be found at sos.mt.gov)
Please send current Voter Information Pamphlet, if applicable to
this election. Audio and large-print versions of the Voter Information
Pamphlet are available online at:
http://www.sos.mt.gov/elections/Disabilities, and a Braille version is
available upon request.
Updated April 6, 2016
Optional - Affidavit of elector (due to illness or health emergency)
Optional: I hereby declare that I am prevented from voting at the polls due
to illness or health emergency occurring between 5:00 p.m. on the Friday
preceding the election and 8 p.m. on election day.
_______________________________________
_______________________________________
Signature of Elector Date Signed
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Individual with a Disability Application for Electronic Absentee (Cascade County)

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Completed 25 January 2021

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