APPLICATION FOR
OFFICIAL ABSENTEE BALLOT
PLEASE PRINT (Failure to fill out the form completely could delay your application)
Date of Primary, Election, or Runoff: (MM/DD/YYYY)
FORM #ABS-APP-18
Voter name
First:
Last:
Middle:
Sux:
Permanent address on le with
county election oce
This is the address at which you are registered OR the
mailing address you have given your county elections
oce. Your ballot will be sent here unless you provide
a valid address in Section 3.
Street:
City: Zip:
County:
Type of ballot
Required in a primary or primary runoff.
Democratic Republican Non Partisan (will not have ANY party candidates listed)
Temporary address where you
want ballot sent
If you wish to receive your absentee ballot at an address
other than the one in Section 2, ll it in here. This ad-
dress must be in a dierent county that the county
listed in Section 2 unless you are physically disabled or
detained in jail or other detention facility.
Street:
City: State:
Zip: County:
Contact information
To assist your county elections ocials in contacting you in a timely manner if your application is
incomplete, please provide the following information.
Phone number: Email:
Signature or mark of voter
Required if voter lls out
this application.
Signature or mark of voter:
Today’s date: (MM/DD/YYYY)
Signature of person providing
assistance
Required if
the voter receives assistance
lling out this form. Assistance is only allowed
if the voter is illiterate or physically disabled.
Name of assistant:
Signature of assistant:
Today’s date: (MM/DD/YYYY)
Signature of person requesting
ballot if not voter
Required only if an eligible relative
is making an application on behalf of
the voter who is physically disabled or
temporarily residing out of the county.
Signature of requestor:
Relationship to voter:
I swear that the facts contained in this application are true and that I am either the mother, father, grandparent, brother, sister, aunt,
uncle, spouse, son, daughter, niece, nephew, grandchild, son-in-law, daughter-in-law, mother-in-law, father-in-law, brother-in-law
or sister-in-law of the age of 18 and swear (or arm) that the above-named voter is
(check one) physically disabled or temporarily residing out of the county
If you meet one of the described
conditions in this section and would
like to receive a mail ballot for the
rest of the elections cycle without
another application, indicate by
checking the applicable eligibility
requirement.
E - Elderly - I am 65 years of age or older D - Disabled - I have a physical disability
U – UOCAVA Voter -
I am a uniformed service member, spouse or dependent of a uniformed
service member, or other US citizen residing overseas.
My current status is (please mark one):
MOS – Military Overseas OST – Overseas Temporary Resident
MST – Military Stateside OSP – Overseas Permanent Resident (federal oces only)
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FOR OFFICE USE ONLY
Dist. Combo: Precinct: Ballot #:
Received Date: ISS Date: Certied Date: Rejection Date:
ID SHOWN: GADL Other:
I certify that the above named voter is eligible is not eligible to receive a vote by mail ballot
Reason for Rejection: Registrar Signature:
Ballot to be: Mailed Electronically Transmitted/delivered to voter in hospital by Registrars/Deputy Voted in oce (municipal only)
Date of birth
Date of birth: (MM/DD/YYYY)
Email:
(required for UOCAVA voters requesting electronic transmission)
Brad Raffensperger
Secretary of State
