Application For Absentee Ballot - Montana Secretary Of State
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1
2Application for Absentee Ballot
Including Absentee List Request, Election Specific Absentee Ballot Request and Request for Absentee Ballot Due to Illness or Health
Emergency
Fields marked with an asterisk (*) are required fields.
Please type or use black or blue pen only and print clearly. COMPLETE FORM AND SUBMIT TO COUNTY ELECTION OFFICE BY NOON THE DAY BEFORE ELECTION DAY
APPLICANT IDENTIFYING AND CONTACT INFORMATION
Last Name*
First Name*
Middle Name
Birthdate* (MM/DD/YYYY)
Phone Number
Email Address
County where you reside and are registered to vote*
Montana Residence Address*
City*
Zip Code*
Mailing Address
City and State
Zip Code
(required if differs from residence address*)
Check if the mailing address listed above is for part of the year only and if so, complete the information below (for absentee ballot list only).
Clearly print the complete mailing address(es) and specify the applicable time periods for address (add more addresses as necessary).
Seasonal Mailing Address
City and State
Zip Code
Period
(mm/dd/yyyy-mm/dd/yyyy)
BALLOT REQUEST OPTIONS AND VOTER AFFIRMATION
I request an absentee ballot to be mailed to me for ALL elections in which I am eligible to vote. I understand that in order to
continue to receive an absentee ballot, I must complete, sign, and return a confirmation notice mailed to me by the county election
office;
OR
I hereby request an absentee ballot for the upcoming election (check only one):
Primary
General
Municipal
Other ________________ election to be held on _____________________
By signing below, I understand that I am officially requesting an absentee ballot, and affirm that I will have met the 30-day Montana
residency requirement before voting my absentee ballot.
(Also sign affidavit at bottom of page if requesting due to illness or health
emergency.)
______________________________________________________________
______________________________
*Signature of Elector
*Date Signed
Optional - Voter Information Pamphlet Request (an electronic version of this pamphlet can be found at sos.mt.gov)
Please send current Voter Information Pamphlet, if applicable to this election
Optional – Designate another person to pick up your absentee ballot
I, the elector who signed above, hereby designate ____________________________________________ to pick up my absentee ballot.
Receipt of absentee ballot by designee: I received the absentee ballot for the applicant on ________________________.
Date ballot received
_________________________________
_________________________________
Signature of Designee
Date Signed
Optional - Affidavit of elector (due to illness or health emergency)
Optional: I hereby declare that I am prevented from voting at the polls due to illness or health emergency occurring between 5:00 p.m.
on the Friday preceding the election and 8 p.m. on election day.
_______________________________________
_______________________________________
Signature of Elector
Date Signed
Updated November 16, 2015
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