I, , do hereby request an absentee ballot for the
Printed name
Election Date
Election Day
he jurisdiction of
the election authority in which I am registered
due t
o 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
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 (6/2020)
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, Zip Code)
At-risk voters are individuals who:
• Are 65 years of age or older • Live in a long-term care facility lincensed 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
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