ATTENTION CLAIBORNE COUNTY ELECTION COMMISSION
I formally "Request an Absentee Ballot" based upon the following information.
1) PRINT NAME AS REGISTERED______________________________________________________________________
2) ADDRESS WHERE YOU LIVE________________________________________________________________________
3) MAIL MY ABSENTEE BALLOT TO THIS ADDRESS_______________________________________________________
4) MY SOCIAL SECURITY # IS___________________________ 5) MY DATE OF BIRTH IS_________________________
6) MY LEGAL REASON FOR VOTING ABSENTEE IS (CHECK ONE )
____I will be outside of this county during all hours of early voting and Election Day (must include mailing address
outside the county)
____I am enrolled as a full-time student or a spouse of a student at an institution inside Tennessee and outside
the county where I am registered. (must include mailing address outside county)
____I am a permanent absentee voter and have a doctor statement on file
____I am hospitalized, ill, or physically disabled and because of such condition I am unable to appear at my
polling place for this election.
____I am a caretaker of a person who is ill or disabled
____I am on jury duty in a state or federal court
____I am over 60 years of age.
____I am a candidate
____I am serving as an election official or a member or an employee of the Election Commission on election day.
____I am observing a religious holiday that prevents me from voting early or election day
____I have a Commercial Driver’s License (CDL) or spouse of a person possessing a CDL or a Transportation
Worker Identification Credential (TWIC) & will be out of the county during early voting & Election Day
& have no specific out-of-county or out-of-state address to receive mail during this time. Enclosed is a copy
Of my CDL or my spouse’s CDL or my TWIC card. The CDL # is_________________________
____I reside in a licensed facility, outside the county, providing relatively permanent domiciliary care, i.e.
Nursing Home (must include mailing address outside county)
____I am a voter covered under the Uniformed and Overseas Citizen Absentee Voting Act (must include mailing
address outside county even if emailing ballot) Ballot to be sent : ____by mail ____email
email address:_______________________________________________________________________
7) I WISH TO VOTE IN THE (PLEASE CIRCLE ONE)
GENERAL ELECTION REPUBLICAN PRIMARY ELECTION DEMOCRAT PRIMARY ELECTION
I swear or affirm, under the penalty of perjury, that all the information on this form is true and correct and that I am eligible to vote
in this election.
8) Signature of Voter______________________________________________________________
If the voter is unable to sign their name or make a mark, the person assisting and one witness must also
sign their names and provide their address.
Person assisting_________________________Name of person witnessing_______________________
FORWARD THIS INFORMATION TO: Claiborne County Election Commission OR Fax to: 423-626-6770
P.O.Box 343
Tazewell, TN 37879
Phone: 423-626-5128
_____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____
FOR CLAIBORNE COUNTY ELECTION OFFICE USE:
(Circle One) This Request has been: Approved or Rejected on __________by______________________________
Precinct_______District_____ID # ________________Application signature verified on__________by_________________
Ballot Sent__________ Ballot Rcvd__________ Ballot Affidavit Signature verified on _________by_________________
