REQUEST FOR MISSOURI ABSENTEE BALLOT
I, , do hereby request an absentee ballot for the
Printed name
Election.
Election Date
Ab
senc
e
on
Election Day
from
t
he jurisdiction of
the election authority in which I am registered
Incapacity
or
c
onfinement
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.
Address where ballot is to be mailed:
(Street Address or PO Box)
Signature of Registered Voter Date
Return this completed form to Kay Brown, Chr
istian County Clerk, 100 W. Church Rm 304, Ozark, MO 65721.
eburton@christiancountymo.gov or dmills@christiancountymo.gov. Phone: 417-582-4340 Fax: 417-581-8331. 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.
(6/2020)
§§ 115.279, 115.283, 115.284, 115.427
PL 107-252
I do solemnly swear that all statements made on this application are true to the best of my knowledge and belief.
Email address:
Telephone number:
(Include Area Code)
Address where I am registered to vote:
(Street Address or PO Box)
(City, State, Zip Code) (City, State, Z
ip Code)
At-risk voters are individuals who:
• Are 65 years of age or older
• Have serious heart conditions
• Are immunocompromised
• Have liver disease
• Live in a long-term care facility licensed under Chapter 198, RSMo.
• Have chronic lung disease or moderate to severe asthma
• Have chronic kidney disease and are undergoing dialysis
• Have diabetes
Reason for requesting an absentee ballot:
If this is a primary election, please print the name of the political party ballot you wish to receive:
For identification purposes: Date of Birth (MM/DD/YY) or last four digits of Social Security number
