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

(HINDI-

sequential

#) (OffICO Use Only)

•

Wisconsin Application for Absentee Ballot

Confidential

Elector ID#

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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:llmyvote.wi.gov

• If you have not previously provided a copy of photo 10, photo 10 must accompany this application. (See instructions for exceptions)

VOTER INFORMATION

Last Name

First Name

DOOR

I ~

Town

I ~

Village

Otty

EGG HARBOR

Municipality

County

Suffix

(e.q.

J,.

II, etc.)

Date of Birth

(MMlDDIYYYY)

Middle Name

Phone

Residence Address: Street Number

Name

Apt. Number

City

State & ZIP

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

OPermanentOverseas

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

State

ZIP

Apt. Number

City

VOTE IN

CLERK'S

Care Facility Name (if applicable)

OFFICE

0 (if applicable)

FAX

Fax Number

Military

and Permanent

Overseas

only

Address.1l1ililary

and Permanent

Oversea-

only

I REQUEST AN ABSENTEE BALLOT BE SENT TO ME FOR:

(mark only one)

OThe

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

OAII 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 Address

Agent Signature

ASSISTANT DECLARATION I 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

Signature

Today's Date

VOTER DECLARATION I 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.

leday's

Date

Voter

Signature

GAB-121 1Rev 2014-09 1Government Accountabillty Board, P.O. Box 7984, Madison, WI 53707-79841608-261-20281 web: gab.wi.gov 1email: gab@wi.gov