New York Accessible Electronic Absentee Ballot Application
Voter Registration Information
Last Name: First Name:
Middle Initial:
Street Address:
City: State:
NY Zip Code: County:
Date of Birth: Phone Number (Optional):
Email Address:
I declare that I am visually impaired or otherwise disabled, and that such disability prevents me from being able to independently
cast a paper absentee ballot, without traveling to a Board of Elections and using a ballot marking device. By submitting this
document, I certify, under penalty of perjury, that I am a United States citizen and that I have a disability and require use of an
accessible electronic absentee ballot in order to vote privately and independently. I further certify that I am a qualified and a
registered (and for primary, enrolled) voter - and that the information in this application is true and correct and that this application
will be accepted for all purposes as the equivalent of an affidavit and, if it contains a material false statement, shall subject me to the
same penalties as if I had been duly sworn.
Sign Here: X Date: / /
WARNING: You must be a United States citizen to vote. If you are not a United States citizen, you will not be issued an absentee
ballot. A person making a false statement in this absentee ballot application is guilty of a misdemeanor.
If applicant is unable to sign because of illness, physical disability or inability to read, the following statement must be executed. by
my mark, duly witnessed hereunder, I hereby state that I am unable to sign my application for an absentee ballot without assistance
because I am unable to write by reason of my illness or physical disability or because I am unable to read/ I have made, or have the
assistance in making, my mark in lieu of my signature/ (No power of attorney or preprinted name stamps allowed/ See detailed
instructions.)
Date: / / Name of Voter: Mark:
I, the undersigned, hereby certify that the above named voter affixed his or her mark to this application in my presence and I know
him or her to be the person who affixed his or her mark to said application and understand that this statement will be accepted for
all purposes as the equivalent of an affidavit and if it contains a material false statement, shall subject me to the same penalties as if
I had been duly sworn.
(Address of Witness to Mark) (Signature of Witness to Mark)
