Fillable Form Gab-121 - Wisconsin Application For Absentee Ballot printable pdf download

Wisconsin Application for Absentee Ballot

SVRS ID #

Confidential Elector ID#

(HINDI - sequential #) (Office Use Only)

(Office Use Only)

Instructions for completion are on the back of this form. Return this form to your municipal clerk when completed.

 Please use uppercase (CAPITAL) letters only. Fill in circles as appropriate.

 You must be registered to vote before you can receive an absentee ballot. You can confirm your voter registration at

https://myvote.wi.gov

VOTER INFORMATION

Town

Municipality

County

Village

City

Last Name

First Name

Date of Birth

Middle Name

Suffix

(e.g. Jr, II, etc.)

(MM/DD/YYYY)

Phone

Fax

Residence Address: Street Number & Name

Apt. Number

City

State & ZIP



If you are a military or permanent overseas elector, fill in the appropriate circle (see instructions for definitions):

Military

Permanent Overseas

I PREFER TO RECEIVE MY ABSENTEE BALLOT BY:

(Ballot will be mailed to the address above if no preference is indicated)



MAIL

Mailing Address: Street Number & Name



VOTE IN

City

State & ZIP

Apt. Number

CLERK’S

Care Facility Name (if applicable)

OFFICE

C / O (if applicable)



Military and Permanent Overseas only

Fax Number

FAX

Email Address



(required for email or

Military and Permanent Overseas only

online delivery)

I REQUEST AN ABSENTEE BALLOT BE SENT TO ME FOR:

(mark only one)



The election(s) on the following date(s): ____________________________________________________________________________





All elections from today’s date through the end of the current calendar year (ending 12/31).



Every election subsequent to today’s date. I further certify that I am indefinitely confined because of age, illness, infirmity or disability and

request absentee ballots be sent to me until I am no longer confined or fail to return a ballot.



TEMPORARILY HOSPITALIZED VOTERS ONLY

(please fill in circle)





I certify that I cannot appear at the polling place on election day because I am hospitalized, and appoint the following person to serve as

my agent, pursuant to Wis. Stat. § 6.86(3).

Agent Last Name

Agent First Name

Agent Middle Name

AGENT: I certify that I am the duly appointed agent of the hospitalized absentee elector, that the absentee ballot to be received by me is

received solely for the benefit of the above named hospitalized elector, and that such ballot will be promptly transmitted by me to that elector

and then returned to the municipal clerk or the proper polling place.

Agent Signature

Agent Address

ASSISTANT DECLARATION / CERTIFICATION

(if required)

I certify that the application is made on request and by authorization of the named elector, who is unable to sign the application due to physical disability.

Agent

Today’s Date

Signature

VOTER DECLARATION / CERTIFICATION

(required for all voters)

I certify that I am a qualified elector, a U.S. Citizen, at least 18 years old, having resided at the above residential address for at least 28 consecutive days

immediately preceding this election, not currently serving a sentence including probation or parole for a felony conviction, and not otherwise disqualified

from voting. Please sign below to acknowledge that you have read and understand the above.

Voter

Today’s Date

Signature

GAB-121 | Rev 2013-11 | Government Accountability Board, P.O. Box 7984, Madison, WI 53707-7984 | 608-261-2028 | web: gab.wi.gov | email: gab@wi.gov