Absentee Ballot Request Form

Purpose: This form allows registered voters to request a mail-in absentee ballot for upcoming elections. Please complete all required fields to ensure your request is processed efficiently by the election authority.

Voter Information

Full Name: {firstName} {lastName}
Date of Birth: {dateOfBirth}
Registered Address: {streetAddress}, {city}, {state} {zipCode}
Phone Number: {phoneNumber}
Email Address: {email}

Ballot Mailing Address (if different from Registered Address)

Street Address: {mailingStreet}
City: {mailingCity}
State: {mailingState}
ZIP Code: {mailingZip}

{#isOutOfState}

Reason for Voting Absentee from Outside Your Registered State: {reasonOutOfState}

{/isOutOfState}

Election Details

Select the elections for which you are requesting an absentee ballot:

{#elections}

• {electionName} - {electionDate}

{/elections}

Delivery Method

Preferred Method of Absentee Ballot Delivery:
{deliveryMethod}

Signature & Certification

I certify that I am a registered voter at the address indicated above and that all the information provided in this form is true and correct. I understand that it is a felony offense to submit false information or to apply for more than one absentee ballot for the same election.

Signature (type full name): {signature}
Date: {signatureDate}

Instructions for Submission

Please submit this completed form to your local election office by the deadline. Submit via:

{#submissionMethods}

• {method}

{/submissionMethods}

For Official Use Only