, do hereby request a mail-in ballot for the
Printed name
Election under Section 115.302, RSMo.
(Street Address)
(City, State, Zip Code)
Address where ballot is to be mailed
(Street Address or PO Box)
(City, State, Zip Code)
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 mail-in ballots must be received by 5:00 p.m. on the second Wednesday prior to
Election Day. 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.
§§ 115.277, 115.302, 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.
Telephone number:
(Include Area Code)
Email address:
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:
where I am
registered to vote:
All mail-in ballots must be notarized.