Fillable Application For Absentee Ballot In-Person Only printable pdf download

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APPLICATION FOR ABSENTEE BALLOT IN-PERSON ONLY

(ABS-IN PERSON)

for Election on _______/________/20__

State Form 42106 (R23 / 10-15); Indiana Election Division (IC 3-11-4-2; 3-11-4-5.1; 3-11-10-26; 3-11-10-26.3)

FOR COUNTY ELECTION BOARD USE ONLY

Precinct

ADDITIONAL

Is applicant required to provide residence identification documentation to the

DOCUMENTATION

county voter registration office but has not yet done so?

Yes

INSTRUCTIONS FOR VOTER: The voter (or the voter’s power of attorney) must SIGN the application below.

If you are applying as the voter’s attorney in fact, a copy of the power of attorney must be attached to this application. If you do not have an attorney in fact and are

Some voters who have registered for the first time in Indiana, and did

physically unable to sign the application, call the County Election Board for assistance.

so by mail, are required to provide additional residence documents. The county election board can tell you if this applies to you. This

application is used for in-person voting at a circuit court clerk’s office (or satellite office), or the board of elections and registration office. If

you are asking that an absentee ballot be sent to you by mail, use form ABS-MAIL. If you are a confined voter who is asking that an absentee

ballot be delivered to you, use form ABS-TRAVELING BOARD. If you are a member of the Attorney General’s address confidentiality program,

use form ABS-ATTORNEY GENERAL. If you are an overseas voter or uniformed services (military) voter, use form ABS-15.

1. INFORMATION OF ABSENTEE BALLOT APPLICANT

Name (please print)

Date of Birth

Last Four Digits of Social Security Number

(mm/dd/yy)

(Completing this box is optional)

______/______/______

____ ____ ____ ____

I do not have a Social Security Number.

Change of Name (If you changed your name since you registered to vote, please print your FORMER NAME to authorize an update to your voter registration record.)

FORMER NAME:

Registration Address (number and street)

City/Town, State, ZIP Code

Telephone Number

(

)

2. COMPLETE THIS SECTION OF APPLICATION TO VOTE IN PRIMARY

Under state law, you must request a major political party ballot to vote in the primary election. However, you may vote on a public

question without voting a political party ballot, if a referendum (public question) is held at the same time as the primary.

I apply for the ballot of the political party, a majority of whose candidates I voted for at the last general election, or whom I intend to vote for

in the next general election: (check one box)

Democratic Party

Republican Party

OR I do not wish to vote in either political party’s primary, but wish to vote on a

Public Question Only

I swear or affirm under the penalties of perjury that

all of the information set forth on this application is true, to the best of my knowledge and belief.

Signature of voter

Date signed (month, day, year)

(or person designated by a county election board to sign for a voter with disabilities)

________/___________/ 20__

3. INFORMATION OF INDIVIDUAL ASSISTING ABSENTEE BALLOT APPLICANT:

Name (please print)

Date Assistance to Applicant Provided

________/___________/ 20__

City/Town, State, ZIP Code

Telephone Number (Day)

Residence Address (number and street)

(

)

Mailing Address (number and street) (If different from residence address)

City/Town, State, ZIP Code

Telephone Number (Evening)

(

)

I swear or affirm under the penalties of perjury that I have no knowledge or reason to believe that the individual submitting the application:

(1) is ineligible to vote or to cast an absentee ballot; or (2) did not properly complete and sign the application.

Signature of Person Assisting Voter with Application

Date signed (month, day, year)

________/___________/ 20__

Penalty for perjury: A person who makes a false, material statement under oath or affirmation, knowing the statement to be false or not believing it to be true

commits perjury, which is punishable by imprisonment for up to 2 ½ years, a fine of up to $10,000, or both.