Form 47090 - Application For Absentee Ballot By Mail Only - Indiana Election Commission
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1APPLICATION FOR ABSENTEE BALLOT BY MAIL ONLY For Election to be held: _______________________
(ABS-2)
State Form 47090 (R4 / 8-99) INDIANA ELECTION COMMISSION (IC 3-11-4-5.1)
To the county election board:
I, ___________________________________________, a registered voter at the address below, apply for an absentee ballot to be Voted By Mail Only, because:
I expect to be out of the county on election day.
I am confined, or expect to be confined, due to illness or injury until after the election; or I expect to be caring for a confined person at a private residence.
I am a voter with disabilities. NOTE: If you are unable to mark the ballot or sign the ballot security envelope, you must contact the county election board to process
your application.
I am a voter at least 65 years of age.
I am scheduled to work at my regular place of employment during the entire 12 hours that the polls are open.
If this application is for a PRIMARY ELECTION check the political party ballot that you are requesting:
DEMOCRATIC
REPUBLICAN
OR Check
School Board only (this option may not be available in all precincts).
NOTE: If you wish to vote by absentee ballot before a travelling board or in person at the county clerk's office, or if you wish for the person holding a power
of attorney to apply for you, contact your county election board.
I affirm under the penalties of perjury that I am a qualified voter who resides in the precinct where I am registered.
/
/
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Voter's signature: ___________________________________________________________
Date of birth: ______________ Daytime Telephone Number: ________________________
ABSENTEE BALLOT MAILING ADDRESS: Please mail the absentee ballot for the election to
REGISTRATION ADDRESS: Fill in IF your absentee ballot mailing address is NOT the
me at this address.
same as your address on the county voter registration records.
FOR OFFICE USE ONLY
Date (mm-dd-yy):
Precinct:
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