Form Av-R1 - Application For Absentee Ballot - Alabama
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1
2APPLICATION FOR ABSENTEE BALLOT
Return this
FORM AV-R1
application
______________________ COUNTY, ALABAMA
to:
General Voter Information -
Please provide complete information so that we may verify your eligibility to vote.
Last Name (Please print)
First Name
Middle or Maiden Name
E-mail Address
Street Address (address where you are registered to vote; do not use PO box)
City
State
ZIP
Mail my ballot to the address where I regularly receive mail, if different from the street address provided above
Precinct where you vote (name and/or location of your polling place)
Date of Birth
Driver’s License Number
IF NO DRIVER’S LICENSE NUMBER
Month
Day
Year
Last 4 digits of
Home Telephone Number
Work Telephone Number
Social Security
number
(
)
(
)
NUMBER
STATE
For all registered voters
I hereby make application for an absentee ballot so that I may vote in the following election:
Primary Runoff Election
Primary Election or Presidential Preference Primary
Select one:
Democratic Party
Select one:
Democratic Party
Republican Party
Republican Party
Other ____________
Other ____________
Amendments Only
Amendments Only
General Election
Special Election (specify) __________________________
If a primary or runoff, check one:
Democratic Party
Republican Party
Absentee ballots for elections more than 42 days apart must be requested on separate applications, unless you are a member
n
or a spouse or dependent of such person,
of the armed forces,
or you are a United States citizen residing overseas.
or a spouse or dependent of such person,
An application submitted by a member of the armed forces,
or a United States
n
citizen residing overseas, is valid for all county, state and federal elections in the current calendar year.
I am applying for an absentee ballot because (check one box):
I will be out of the county or the state on election day.
I have a physical illness or infirmity which prevents my attendance at the polls.
I have a physical illness or infirmity which prevents my attendance at the polls. I am unable to access my assigned
polling place due to a neurological, musculoskeletal, respiratory (including speech organs), cardiovascular, or other
life-altering disorder that affects my ability to perform manual tasks, stand for any length of time, walk unassisted,
see, hear or speak and:
a) I am an elderly voter aged 65 or older; or
b) I am a voter with a disability.
I work a shift which has at least ten (10) hours that coincide with the polling hours at my regular polling place.
I am enrolled as a student at an educational institution located outside the county of my personal residence,
attendance at which prevents my attendance at the polls.
I am a member of, or a spouse or dependent of a member of, the Armed Forces of the United States or am other-
wise similarly qualified to vote absentee pursuant to the Uniformed and Overseas Citizens Absentee Voting Act,42
U.S.C. 1973ff.
This application for an absentee ballot will be valid for all county, state, and federal elections held during this
calendar year unless you specify an earlier expiration date here: _______________________________.
I have been appointed as an election officer at a polling place which is not my regular polling place.
When I apply for this absentee ballot, I understand that my name will be stricken from the list of qualified electors and,
when I cast this absentee ballot, I understand that I will not be entitled to vote at my regular polling place.
Voter’s Signature
Witness Signature
Complete this
section if voter
Print Witness Name
signs by mark
The voter may hand this application to the Absentee Election Manager. The voter may also forward this application to the Absentee Election
Manager by U.S. Mail [§17-11-3 and §17-11-4, Code of Alabama, 1975]. Do not include more than one application per envelope if mailing.
READ PENALTIES ON BACK
Revised 2016.08.02
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