Form Abs-App-10 - Application For Official Absentee Ballot

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_________________________ COUNTY or MUNICIPALITY

GA Driver’s License # ____________________

APPLICATION FOR OFFICIAL ABSENTEE BALLOT

PLEASE PRINT

(FAILURE TO FILL OUT THE FORM COMPLETELY COULD DELAY YOUR APPLICATION)

_____/_____/20____

Date of Primary, Election, or Runoff:



FOR PRIMARY ELECTIONS ONLY, CHOOSE A PARTY BALLOT (check only one):

DEMOCRATIC

REPUBLICAN

APPLICATION

DATE OF BIRTH

DAYTIME CONTACT

EMAIL ADDRESS(required for UOCAVA

DATE

NUMBER (optional)

Voter requesting electronic transmission)

_____/_____/_____

(______) ______-_______

NAME AS REGISTERED

LAST

FIRST

MIDDLE

ADDRESS AS REGISTERED

STREET #

CITY

ZIP CODE

Mail the ballot to my temporary out-of-county address: (or alternate address for physically disabled voter).

# STREET

CITY

STATE

ZIP CODE

Note: You must file a separate application for each election for which you are requesting an absentee ballot (*see

exceptions below for voters over the age of 75, disabled, or military or overseas citizens). You may file your application

up to 180 days prior to the Date of the Election.

* EXCEPTIONS:

If you meet the following criteria,

you may choose to complete one application and receive a ballot for the General Primary,

General Primary Runoff (if any), General Election, and General Election Runoff (if any) by checking one of the following boxes:

E - Elderly - I am 75 years of age or older.

D - Disabled - I have a physical disability.

U – UOCAVA Voter - Member of armed forces or Merchant Marines of the United States, commissioned corps of the Public

Health Service or the National Oceanic and Atmospheric Administration, spouse or dependent residing with or accompanying said

member, or a United States citizen residing overseas. My current status is (please mark one):

MOS – Military Overseas

MST – Military Stateside

OST – Overseas Temporary Resident

OSP – Overseas Permanent Resident (federal offices only)

For UOCAVA Voters Only -

I would like to receive my absentee ballots by electronic transmission

NOTE: A SEPARATE APPLICATION IS REQUIRED FOR A PRESIDENTIAL PREFERENCE PRIMARY

__________________________________

_____________________________________________

SIGNATURE OR MARK* OF VOTER -

REQUIRED

*Signature of person preparing application if voter is disabled or illiterate -

REQUIRED

You may apply on behalf of another person only in the following circumstances: In the case of a voter residing temporarily out of the county or a physically

disabled voter residing within the county, application may be made by mother, father, grandparent, brother, sister, aunt, uncle, spouse, son, daughter, niece,

nephew, grandchild, son-in-law, daughter-in-law, mother-in-law, father-in-law, brother-in-law or sister-in-law of the age of 18 or over upon completing the following

oath: I, the undersigned do swear (or affirm) that the above-named voter is (check one):

residing temporarily out of the county or is a

physically disabled

voter residing within the county and that the facts included in this application are true.

_______________________________________________________________________________

SIGNATURE AND RELATIONSHIP OF RELATIVE REQUESTING BALLOT - REQUIRED

OFFICE USE ONLY

Voter Registration #_________________________

DIST. COMBO

PRECINCT

I HEREBY CERTIFY THAT THE ABOVE NAMED VOTER

PACKET PREPARED BY: