REQUEST FOR MISSOURI ABSENTEE OR MAIL-IN BALLOT
GENERAL ELECTION - NOVEMBER 3, 2020
Voter’s Name: __________________________________________________________________________________________
or last four digits of Social Security number For identification purposes: Date of Birth (MM/DD/YY) ___________ _________
Registered Voting Address: _____________________________________________________________________________
ZIP Code:City: _________________________________________________________________ _____________________
Email Address: Telephone Number: ___________________________ __________________________________________
Address to which ballot is to be mailed (if different than above):
Address: ____________________________________________________________________________________________
ZIP Code:City: _________________________________________________________________ _____________________
ABSENTEE BALLOT REQUEST (select ONE reason):
(NOTARY REQUIRED UNLESS SPECIFICALLY NOTED BELOW)
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. (No Notary Required)
______
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, RSMo.,
. because of safety concerns
______
I have contracted or am in an at-risk category for contracting or transmitting severe acute respiratory syndrome . .
coronavirus 2 (COVID-19), pursuant to Section 115.277.6, RSMo. (No Notary Required)
______
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
• Have chronic kidney disease and are undergoing dialysis
.
If you request an absentee ballot, this form may be returned to your local election authority in person, by mail, by fax, or by email.
MAIL-IN BALLOT REQUEST:
(NOTARY REQUIRED FOR ALL MAIL-IN BALLOTS)
_____ Any registered voter can request a mail-in ballot. If selecting this option, this form must be delivered
Signature of Registered Voter Date
Return this completed form to your local election authority. Contact information can be found on the Missouri Secretary of State’s
website. Missouri law requires that requests for ballots to be mailed to you must be received by 5:00 p.m. on October 21, 2020.
to your local election authority in person or by mail only.
I do solemnly swear that all statements made on this application are true to the best of my knowledge and belief.
