Application For Advance Ballot By Mail Form
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1
2Office of the Kansas Secretary of State
Application for Advance Ballot by Mail
FORM
AV1M
DOWNLOAD THIS FORM AT
1. Affirmation
Affirmation of an Elector of the County of ____________________ and State of Kansas Desiring to Vote an Advance Voting Ballot
State of ____________________, County of ____________________, ss: (where application is completed)
2. Voter Identification Requirements
I understand that my current and valid Kansas driver’s license number or Kansas nondriver’s identification card number
must be provided in order to receive a ballot.
Current Kansas driver’s license number or nondriver’s identification card number: ________________________________
If I do not have a current and valid Kansas driver’s license number or Kansas nondriver’s identification card number, I
must provide a copy of one of the following forms of photo identification with this application in order to receive a ballot:
•
Driver’s license issued by Kansas or another state
•
Employee badge or ID document issued by a government office
•
Nondriver’s ID card issued by Kansas or another state
•
U.S. military ID
•
U.S. passport
•
Student ID card issued by an accredited Kansas postsecondary
•
Concealed carry of handgun license issued by Kansas
educational institution
or another state
•
Public assistance ID card issued by a government office
3. Personal Information
Please print.
______________________________
______________________________
____
__________________________
Last Name
First Name
M.I.
Date of Birth (MM/DD/YY)
__________________________________________
_______________________
__________
_____________
Residential Address
City
State
Zip Code
□
□
Political Party (To be filled in only when requesting a primary election ballot):
Democratic
Republican
4. Address to Mail Ballot (if different from residential address)
__________________________________________
_______________________
__________
_____________
Mailing Address
City
State
Zip Code
Note: The ballot may be mailed only to the voter’s residential or mailing address as indicated on the county voter registration list, to the voter’s
temporary residential address, or to a medical care facility where the voter resides. These restrictions do not apply to a voter who has an illness,
disability or who lacks proficiency in the English language. Ballots cannot be mailed until 20 days before the election.
5. Voter Signature
Note: False statement on this affirmation is a severity level 9, nonperson felony.
I do solemnly affirm under penalty of perjury that I am a qualified elector residing at the address listed above. I am
entitled to vote an advance voting ballot and I have not voted and will not otherwise vote at the election to be held on
____________________ (date).
______________________________
______________________________
________________________
Required
Signature of Voter
Date (MM/DD/YY)
Phone Number
FOR OFFICE USE ONLY Date App. Rec’d. ____________ Ballot Mailed ____________ Transmitted by ____________
Prepared by the Offi ce of Secretary of State Kris W. Kobach, 1st Floor, Memorial Hall,120 S.W. 10th Avenue, Topeka, KS 66612-1594.
KSA 25-1122d(a). Rev 7/3/12 nr
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