Request to be on Permanently Disabled Absentee List

"*" indicates required fields

First Name*

Last Name*

I declare that I am a resident and registered voter of Cape Girardeau County, Missouri, and am permanently disabled. I hereby request that my name be placed on the election authority’s list of voters qualified to participate as absentee voters pursuant to section 115.284, and that I be delivered an absentee ballot application for each election in which I am eligible to vote.

Voter's Home Address*

City*

State*

Zip Code*

Voter's Mailing Address*

City*

State*

Zip Code*

Date of Birth*

Last 4 Digits of SSN*

Phone Number*

Signature

Name

This field is for validation purposes and should be left unchanged.

Request to be on Permanently Disabled Absentee List

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