(6/2020)
REQUEST FOR MISSOURI ABSENTEE BALLOT
I, , do hereby request an absentee ballot for the
Printed name
Election.
Election Date
For identification purposes: Date of Birth (MM/DD/YY) or last four digits of Social Security number
If this is a primary election, please print the name of the political party ballot you wish to receive:
Reason for requesting an absentee ballot:
Absence on Election Day from the jurisdiction of the election authority in which I am registered
Incapacity
or
confinement
due to illness
or
physical
disability,
including caring for
a person
who is
incapacitated
or
confined due to illness
or
disability
Religious
belief or practice
Employment as an election authority or by an election authority at a location other than my polling place
Incarceration, although I have retained all the necessary qualifications for voting
Certified
participation in the address
confidentiality
program
established under
sections
589.660
to
589.681
because of
safety
concerns
I have contracted or am in an at-risk
category for contracting or transmitting severe acute respiratory syndrome
coronavirus 2, pursuant to Section 115.277.6, RSMo.
At-risk voters are individuals who:
• Are 65 years of age or older • Live in a long-term care facility licensed under Chapter 198, RSMo.
• Have serious heart conditions • Have chronic lung disease or moderate to severe asthma
• Are immunocompromised • Have chronic kidney disease and are undergoing dialysis
• Have liver disease • Have diabetes
Address where I am registered to vote:
A
ddress where ballot is to be mailed:
(Street Address or PO Box)
(
Street Address or PO Box)
(City, State, Zip Code) (
City, State, Zip Code)
Telephone number:
(Include Area Code)
Email address:
I do solemnly swear that all statements made on this application are true to the best of my knowledge and belief.
Signature of Registered Voter Date
Mail this completed form to your local election authority. Addresses can be found on the Missouri Secretary of State’s website.
Missouri law requires that requests for absentee ballots must be received by 5:00 p.m. on the second Wednesday prior to Election
Day if the ballot is mailed. The deadline for absentee voting in person in the office of the election authority is 5:00 p.m. on the
day before the election. If you registered by mail and this is your first time voting, you must provide a copy of either: (1) an ID
issued by the Federal Government, state of Missouri, or a local election authority; (2) ID issued by a Missouri institution
(public or private) of higher education; or (3) a current utility bill, bank statement, paycheck, government check or other
government document that contains your name and address.
§§ 115.279, 115.283, 115.284, 115.427
PL 107-252
