State Of Iowa Official Absentee Ballot Request Form
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1Ye a r
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State of Iowa
Official Absentee Ballot Request Form
REQUIRED Information
Form 3A (Rev 01-08)
*
If you don’t have an Iowa driver’s license or non-operator ID, provide the last 4 digits of your Social Security Number.
Date of Birth
1.
Valid IA Driver’s License or IA Non-Operator ID Number
Last 4 Digits of SSN #
/
/
OR
( M o n t h / D a y / Ye a r )
FOR OFFICE USE ONLY
*
Last Name
First Name
Middle Name
Suffix ( Sr., Jr., etc.)
Name
2.
*
Street Address (include apt., lot, etc., if applicable)
*
ZIP
City
State
Daytime Phone, Cell Phone or Email
Former Name (if applicable)
3.
I have moved.
The above address represents my NEW address.
Please change my voter record accordingly.
Complete section #4 ONLY if the ballot is to be mailed to an address different than the address in section #2.
Mailing Address (include apt., lot, etc., if applicable)
4.
ZIP
City
State
Country (other than USA)
*
OR
Party Affiliation
Date of the Election
Name of the Election for this Absentee Ballot Request
(for Primary Elections Only)
/
/
Check only
General
Primary
School
5.
Democratic
Republican
ONE
Box
NOTE: If your voter registration record shows a political party different from the one you check above,
City
Special ________________
( M o n t h / D a y / Ye a r )
your registration will be changed to the political party you check on this form.
*
X
6.
________________________________________________________________________________
_________________________________
Signature of Voter
Date
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