Request for Absentee Ballot by Voter

"*" indicates required fields

First Name*

Last Name*

Date of Birth*

Last 4 Digits of SSN*

Election Date - Name*

Please indicate the name of the Political Party ballot you wish to receive (for Primary Elections only):

I do hereby request an absentee ballot for the above selected election date.

Reason for requesting an absentee ballot*

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 on election day, including caring for a person who is incapacitated or confined due to illness or physical disability and resides at the same address

Religious belief or practice

Employment as an election authority, by an election authority at a location other than my polling place, as a first responder, as a health care worker, or as a member of law enforcement

Incareration, 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

My home address where I am registered to vote:*

City*

State*

Zip Code*

Address where ballot is to be mailed:*

City*

State*

Zip Code*

Phone Number*

I do solemnly swear that all statements made on this application are true to the best of my knowledge and belief.

The deadline to submit this request to have an absentee ballot mailed to you is 5:00 p.m. on the 2nd Wednesday prior to the election. The deadline for absentee voting in person in the office is 5:00 p.m. on the day before the election. For questions contact the County Clerk’s Office: (573)243-3547.

Signature

Comments

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Request for Absentee Ballot by Voter

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