Ofce of the Kansas Secretary of State
Application for Permanent Advance Voting Status
1. Afrmation
Afrmation of an Elector of the County of ______________________ and State of Kansas Applying for Permanent
Advance Voting Status
State of _________________, County of ______________________, ss: (where application is completed)
2. Applying for Permanent Advance Voting Status
Applicants for permanent advance voting status must have a permanent physical disability or illness or have been diagnosed
as having a permanent illness. The nature of my permanent disability or illness is:
3. Personal Information Please print.
___________________________________ ___________________________________ _____
Last Name First Name M.I.
Residential Address
______________________________________________ ________ _____________________
City State Zip Code
Political Party:
Republican Date of birth: _____________________
4. Address to Mail Ballot (if different from residential address)
Mailing Address
______________________________________________ ________ _____________________
City State Zip Code
Note: The ballot may be mailed only to the voter’s residential or mailing address as indicated on the county voter registration list, to the voter’s
temporary residential address, or to a medical care facility where the voter resides. These restrictions do not apply to a voter who has an illness,
disability or who lacks prociency in the English language. Ballots cannot be mailed until 20 days before the election.
5. Voter Signature Note: False statement on this afrmation is a severity level 9, nonperson felony.
I do solemnly afrm under penalty of perjury that I am a qualied elector, residing at the address listed above, or I am
authorized to sign for the above named voter who has a disability preventing the voter from signing an application. I
further afrm that I will not vote more than once at any election.
______________________________ ______________ _____________________
Signature of Voter Date (MM/DD/YY) Phone Number
Prescribed by the Ofce of the Secretary of State, 1st Floor, Memorial Hall, Topeka, KS 66612-1594.
KSA 25-1122d(c). Rev 1/14/19 tc
FOR OFFICE USE ONLY Date App. Rec’d. ____________
Please complete the form, sign and send
to the Kansas Secretary of State.
Selecting "Print" will print the form and
"Reset" will reset the entire form.
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