PAGE 1
REQUEST TO CANCEL MY BALLOT REQUEST
STEP 1:
Fill out the form
STEP 2:
Sign and date the form
STEP 3:
Mail or deliver to your county voter
registration ofce (see list on page 2)
This form can only be completed by the voter.
08/2020
By submitting this form, you’re requesting the following:
• You no longer wish to receive a mail ballot for the upcoming election and request for your ballot request
to be canceled.
• If you are a permanent or annual voter, you are also requesting for your permanent status to be canceled
and to cancel all ballot requests for any upcoming election(s). If you would like to receive a mail ballot in
the future, you’ll need to reapply for one.
(A permanent or annual mail-in voter is someone who requested to receive a mail-in ballot automatically
for every election for which they’re eligible that year. The voter is then given a choice to renew this
request each future year if they choose.)
Printed Name
First name Middle name or initial
Last name
Jr Sr ll lll lV
1
Identication
This information
will only be used to
locate your record
on le and process
your request. Your
ID information will
be condential.
Last four digits of your Social Security number X X X - X X -
PA driver’s license or PennDOT ID card number
Date of birth
MM/DD/YYYY
or
2
Address
Please write the
address where
you are registered
to vote in
Pennsylvania.
Street Address (Not P.O. Box)
Apt. #
Municipality County
City/Town State Zip Code
3
Contact
Please add
your contact
information in
case there are any
questions.
Phone
(Optional) ###-###-####
Email (Optional)
4
Signature
Date
5
False statements on this form are punishable pursuant to 18 Pa.C.S. § 4904 (relating to unsworn
falsication to authorities).
NOTICE
!
6
