§32-941 Updated June 2020
Nebraska Early Voting
Ballot Application
Date: _____________________
Applications must be physically signed. You can take a picture or scan your request and email it to your county election official. You
can also mail or fax your application to your county election office.
I, the undersigned, declare that I am a registered voter in Nebraska. I am registered at the following address:
____________________________________________________________________, in _________________ County.
I am requesting early voting ballots for the following Election: General Special (Other)
(Note: The first day to request an early voting ballot is 120 days before an election)
to be held on _______________ _____, 20______.
I request to vote in the Election Office today as the Early Voting Polling Place.
I request that ballots be mailed to me, (or to the person I am acting as agent for), at the following address:
Address Line 1: ___________________________________________________________
Address Line 2: ___________________________________________________________
City, State, Zip: ___________________________________________________________
I request to take the ballots with me, (or to the person I am acting as agent for, up to two people).
To confirm any information prior to sending the ballots, the Election Office may reach me at:
Phone: _____________________________ Email: _______________________________________
Voter’s Printed Name: ____________________________ Voter’s Signature: ______________________________
Voter’s Date of Birth (MM/DD/YYYY) ____ /____ /________
If applying for another voter: Agent’s Signature: _______________________________ Relationship: _______________
The penalty for election falsification is imprisonment for up to two years imprisonment
and twelve months post-release supervision, a fine of up to ten thousand dollars, or both.
Return completed application to:
______________ County Election Office
__________________, NE _________
Election Office Use Only
Application Number: __________
Date Received: _________ Date Sent: ___________
Voter ID Number: _____________ Ballot Assigned: ___________ Staff initials: _______