REQUEST FOR ACCESSIBLE REMOTE
BALLOT FOR NOVEMBER 3, 2020
PENNSYLVANIA GENERAL ELECTION
DOS-09/2020
Instructions:
Read the following document carefully. Complete this form to request a remote accessible ballot. In order to
apply for an accessible remote ballot, you must have applied for an absentee or mail-in ballot
ApplyMailBallot). To avoid delays in processing your request, please submit your request within 24 hours of
applying for your mail-in or absentee ballot.
(votesPA.com/
Complete all the required elds. Required elds are marked with an asterisk. (*)
Enter your name, date of birth, county of residence, address, and identifying information, and sign your name
and date where indicated. You may electronically sign your name. Print this completed request form and mail
it to your County Board of Elections. The mailing address can be found at Or you may
alternatively email the completed request form to ra-awib@pa.gov.
votespa.com/county.
Request for Accessible Remote Ballot
By entering and signing my name below I am requesting an accessible remote ballot for the November 2020
Pennsylvania General Election.
Declaration
By entering and signing my name below, I declare and afrm that: I am a voter with a disability as dened by
the Americans with Disabilities Act; I am eligible to vote at the forthcoming election; I have not already voted in
the election; and, all of the information I have provided on this form is true and correct and is made subject to
the penalties of 18 Pa.C.S. § 4904 (relating to unsworn falsication to authorities).
Required elds are marked with an asterisk. (*)
1
Applicant
Information
*Last name
Jr Sr ll lll lV
*First name Middle name or initial
*Phone number
(###-###-####)
*Birthdate (MM/DD/YYYY)
*Email Address
2
Address
where
registered
to vote
*County
*Street Address (Not P.O. Box)
Apt. #
*City/Town
State
PA
*Zip Code
3
Address
where you
receive mail
Same as above
Street Address
Apt. #
City/Town
State Zip Code
4
*Sign your
name or
mark here
Date
click to sign
signature
click to edit
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