Application For Mail Ballot Form
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P
TATE OF
HODE
SLAND AND
ROVIDENCE
LANTATIONS
Office of the Secretary of State
CERTIFICATION OF PERMANENTLY DISABLED
OR INCAPACITATED VOTER FOR AUTOMATIC
APPLICATION FOR MAIL BALLOT
TO THE BOARD OF CANVASSERS FOR THE CITY/TOWN OF __________________________________________
I. (Please fill in this section.)
I, ______________________________________________________________, certify that I am a qualified voter of
(Please print name)
the City/Town of ______________________________________________________________, and am indefinitely
confined because of physical illness or infirmity or because I am disabled for an indefinite period.
I request that a mail ballot application be sent to me automatically for every election hereafter to be conducted in said
city/town.
II. (This section is optional - fill in only if you want to receive a mail ballot application for primaries.)
I further request that a mail ballot application be sent to me for each ______________________________________
(Name of Party)
Primary.
III. (Please fill in this section.)
My application is to be mailed to __________________________________________________________________
street address
apartment #
____________________________________________________________________________________________
city/town
state
zip
Dated at ________________________________________, this __________ day of ____________________, 20____
____________________________________________
Signature of Voter
In __________________subscribed and sworn before me this ____________ day of ____________________, 20 ____
____________________________________________
Notary Public
NOTICE TO DISABLED OR INCAPACITATED VOTER
This certification entitles you to automatically receive a mail ballot application for every election held in your
city or town.
The application will not be forwarded to any address other than the one stated above in your certification. It is
your duty to notify the local board of canvassers that you are no longer indefinitely confined.
E-90-ND-2006
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