Abbm-Application For Ballot By Mail-English - Texas Secretary Of State

DO NOT REMOVE PERFORATED TABS. Moisten here and fold bottom to top to seal.

DO NOT REMOVE PERFORATED TABS. Moisten here and fold bottom to top to seal.

Application for Ballot by Mail

Prescribed by the Office of the Secretary of State of Texas

For Official Use Only

A5-15e 08/15

VUID #, County Election Precinct #,

Statement of Residence, etc.

Last Name (Please print information)

Suffix (Jr., Sr., III, etc)

First Name

Middle Initial

1

,

TX

Residence Address: See back of this application for instructions.

City

Zip Code

2

Mail my ballot to: If mailing address differs from residence address, please complete Box # 7.

City

State

Zip Code

3

Date of Birth (mm/dd/yyyy) (Optional)

4

Reason for Voting by Mail:

If you are requesting this ballot be mailed to a different address (other than residence), indicate where the ballot

5

7

will be mailed. See reverse for instructions.

65 years of age or older. (Complete Box #6a)

Mailing Address as listed on my voter registration certificate

Address of the jail

Disability. (Complete Box #6a)

Nursing home, assisted living facility, or long term care facility

Relative; relationship _________________

Expected absence from the county. (Complete Box #6b and Box #8)

You will receive a ballot for the upcoming election only

Hospital

Address outside the county (see Box #8)

Confinement in jail. (Complete Box #6b)

Retirement Center

You will receive a ballot for the upcoming election only

ONLY Voters 65 Years of Age or Older or Voters with a Disability:

6a

8

If you selected “expected absence from the county,” see reverse for instructions

If applying for one election, select appropriate box.

If applying once for elections in the calendar year, select “Annual Application.”

Annual Application

Date you can begin to receive mail at this address

Date of return to residence address

Uniform and Other Elections:

Primary Elections:

You must declare one political party to vote in

May Election

9

Contact Information (Optional)*

Notice to Voter: Effective September 1, 2015, you may submit a

a primary:

completed, signed and scanned application to the early voting clerk at

Please list phone number and/or email address:

November Election

Democratic Primary

* Used in case our office has questions.

Other ___________________

________________________________________________________

Republican Primary

(early voting clerk’s e-mail address)

Any Resulting Runoff

ONLY Voters Absent from County or Voters Confined in Jail:

“I certify that the information given in this application is true, and I understand that giving false information

6b

10

You may only apply for a ballot by mail for one election, and any resulting runoff.

in this application is a crime.”

X

Please select the appropriate box.

Uniform and Other Elections:

Primary Elections:

You must declare one political party to vote in

Date

May Election

a primary:

November Election

Democratic Primary

SIGN HERE

Other ___________________

If applicant is unable to sign or make a

Republican Primary

mark in the presence of a witness, the

Any Resulting Runoff

witness shall complete Box #11.

If someone helped you to complete this form or mails the form for you, then that person must complete the sections below.

11

See back for Witness and Assistant definitions.

If applicant is unable to mark Box #10 and you are acting as a Witness to that fact, please check this box and sign below.

If you assisted the applicant in completing this application in the applicant’s presence or e-mailed/mailed or faxed the application on behalf of the applicant, please check this box as an Assistant and sign below.

*

If you are acting as Witness and Assistant, please check both boxes.

Failure to complete this information is a Class A misdemeanor if signature was witnessed or applicant was assisted in completing the application.

X

X

Signature of Witness /Assistant

Printed Name of Witness/Assistant

Witness’ Relationship to Applicant

(Refer to Instructions on back for clarification)

Street Address

Apt Number (if applicable)

City

State

Zip

Este formulario está disponible en Español. Para conseguir la version en Español favor de llamar sin cargo al 1.800.252.8683 a la oficina del Secretario de Estado o la Secretaria de Votación por Adelantado.