New York State Absentee Ballot Application

Transcript

1 BOARD USE ONLY: New York State !bsentee Ballot !pplication Town/City/Ward/Dist: Please print clearly; See detailed instructions/ _________________________________ This application must either be personally delivered to your county board of elections not Registration No: ____________________ later than the day before the election, or postmarked by a governmental postal service Party: ____________________________ not later than 7th day before election day; The ballot itself must either be personally delivered to the board of elections no later than the close of polls on election day, or voted in office  postmarked by a governmental postal service not later than the day before the election and received no later than the 7th day after the election/   I am requesting, in good faith, an absentee ballot due to (check one reason) :  1/  absence from county or New York ity on election day  sident or patient of a Veterans Healt  re h  ministration Hospita l !d  ty temporary illness or physical disabili   ty ermanent illness or physical disabili p  g etention in jail/prison, awaiting trial, awaitin d    d re uties related to primary care of one or mo  action tion by a grand jury, or in prison for a convic dividuals who are ill or physically disable d in o y f a crime or offense which was not a felon absentee ballot(s) requested for the following election(s) . 2/ ecial Election on Primary Election only General Election on  Sp ly  ly  y election held between these dates. absence begins. __ absence ends. _____/_____/____ _/_____/_____ !n __ _  MM/DD/YYYY MM/DD/YYYY first name last name or surname middle initial suffix 3/ email (optional) county where you live phone number (optional) date of birth MM/DD/YYYY 4/ _____ /_____ /_____ zip code city apt address where you live (residence) street state 5/ NY (check one)  s Delivery of Primary Election allot Deliver to me in person at the board of election 6/ s/ to pick up my ballot at the board of election ______________ ._________________________ (give name)  I au thorize ail ballot to me at.  M (mailing address) _____________ _______________________ __ _____________ _______________ _____________________________________ street no/ apt/ city state zip code street name  s Deliver to me in person at the board of election (check one) Delivery of General (or Special) Election allot 7/ (give name) . ______________________________________ to pick up my ballot at the board of election s/  I au _ thorize (mailing address)  M ail ballot to me at. ____________ ________________ __________________ _ _____ ______________ __ _____________________ _______________ city state zip code street no/ street name apt/ !pplicant Must Sign Below I certify that I am a qualified and a registered (and for primary, enrolled) voter-and that the information in this application is 8/ true and correct and that this application will be accepted for all purposes as the equivalent of an affidavit and, if it contains a material false statement, shall subject me to the same penalties as if I had been duly sworn/ Date X__________________________ Sign Here: ____/____/____ MM/DD/YYYY If applicant is unable to sign because of illness, physical disability or inability to read, the following statement must be executed. y my mark, duly witnessed hereunder, I hereby state that I am unable to sign my applica- tion for an absentee ballot without assistance because I am unable to write by reason of my illness or physical disability or because I am unable to read/ I have made, or have the assistance in making, my mark in lieu of my signature/ (No power of attorney or preprinted name stamps allowed/ See detailed instructions/) Date ___/___/___ Name of Voter.___________________ _________________ Mark._ __________________ MM/DD/YYYY I, the undersigned, hereby certify that the above named voter affixed his or her mark to this application in my pres- ence and I know him or her to be the person who affixed his or her mark to said application and understand that this statement will be accepted for all purposes as the equivalent of an affidavit and if it contains a material false statement, shall subject me to the same penalties as if I had been duly sworn/ ______________________________________ _____________________________________________ _____________________________________________ (signature of witness to mark) (address of witness to mark) Board Use Only 2015 Absentee Ballot Application

2 Instructions: Who may apply for an absentee ballot? Each person must apply for themselves/ It is a felony to make a false statement in an application for an absentee ballot, to attempt to cast an illegal ballot, or to help anyone to cast an illegal ballot/ Information for military and overseas voters: If you are applying for an absentee ballot because you or your family are in the military or because you currently reside overseas, do not use this application/ You are entitled to special provisions if you apply using the Federal Postcard !pplication/ For more information about military/overseas voting, contact your local board of elections or refer to the Military and Federal Voting sections at. http.//www/elections/ny/gov/Voting/html Where and when to return your application: delivered to your county - !pplications must be mailed seven days before the election, or hand board of elections by the day before the election; If the address of your county board of elec - tions is not provided on this form, contact information for your local election office can be found on the New York State oard of Elections’ website, under “ounty oards of Election” directory” at. http.//www/elections/ny/gov/ountyoards/html Options available to you if you have an illness or disability: - If you check the box indicating your illness or disability is permanent, once your application is ap proved you will automatically receive a ballot for each election in which you are eligible to vote, without having to apply again/ You may sign the absentee ballot application yourself, or you may make your mark and have your mark witnessed in the spaces provided on the bottom of the appli- cation/ Please note that a power of attorney or printed name stamp is not allowed for any voting purpose/ When your ballot will be sent: Your absentee ballot materials will be sent to you at least 32 days before federal, state, county, city or town elections in which you are eligible to vote/ If you applied after this date, your ballot will be sent immediately after your completed and signed application is received and processed by your local board of elections/ If you provide dates in section 2, identifying the time frame within which you will be absent from your county or from the ity of New York, you will be sent a ballot for any primary, general, special election or presidential primary election which might occur during the time frame you have specified/ If you prefer, you may designate someone to pick up your ballot for you, by completing the required information in section 6 and/or section 7, as appropriate/ ontact your local county board of elections if you have not received your ballot/

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