Application For Absent Voter'S Ballot printable pdf download

Application for Absent Voter’s Ballot

Complete and return to:

Approved By______________

City Clerk’s Office, 226 North Michigan Avenue, Big Rapids, MI 49307

FOR THE____________________ ELECTION TO BE HELD ON _______________, 20_____

I, _______________________________________, a duly qualified and registered elector in the ________ Precinct

of the City of Big Rapids, in the County of Mecosta, and State of Michigan, hereby make application for an official

ballot, or ballots, to be voted by me at such election.

: _____________________

***

Registered Address

Check reason(s) why you are requesting a ballot. If a reason is

not checked for an election, an absentee ballot will not be issued for

that election.

___________________________________

WARNING: A person who makes a false statement in this Declaration

is guilty of a misdemeanor.

Big Rapids, MI 49307

I am 60 years of age or older.

I expect to be absent from the community in which I am

registered for the entire time the polls are open on election

day.

CHECK REASON

I am physically unable to attend the polls without the

FOR REQUESTING

assistance of another.

AV BALLOT HERE

I cannot attend the polls because of the tenets of my religion.

I have been appointed an election precinct inspector in a

precinct other than the precinct where I reside.

I cannot attend the polls because I am confined to jail awaiting

arraignment or trial.

I declare the foregoing statement(s) to be true

SIGN

HERE

X___________________________________________________

_______/_______/______

(SIGNATURE OF ABSENT VOTER)

(DATE)

NOTE: Michigan law requires that A.V. Ballots be sent to your registered address unless you are hospitalized, institutionalized, or at an address

outside of your community. Complete the following ONLY if you want your ballot sent to an address outside of your community or to a hospital

or other institution.

DO NOT COMPLETE UNLESS YOU WANT BALLOT SENT TO OTHER THAN YOUR REGISTERED ADDRESS

I will not be at my registered address,

________ _________________________________________________________

therefore send “Absent Voter Ballot”

to me at:

________ _________________________________________________________

(NO.)

(STREET)

________ _________________________________________________________

(CITY)

(STATE)

(ZIP)

(Clerk’s Use Only)

Filed: ________/________/________

Mailed: ________/________/________

Returned: ________/________/________

Wd/Pct: _______________________

Ballot No: _______________________

Clerk: ____________________________

DO NOT DETACH

SEE REVERSE SIDE FOR ADDITIONAL INSTRUCTIONS AND WARNINGS

APPLICATION TO VOTE – POLL LIST -(ABSENT VOTER)

I hereby certify that I am a registered and qualified elector in the ward and precinct above and hereby make application to vote at the above indicated election.

X______________________________________________________________

(Signature of Absent Voter)

____________________________________________________________________

________________________

(PLEASE PRINT FULL NAME)

(Date of Birth)

________________________________________________________________________________________________________________

(Present Street Address)

INSPECTORS USE ONLY

___________________________

Voter No.

________________________________________

___________________________

Date of Election

Ward/Precinct No.

________________________________________

___________________________

Ballot No. Issued

Inspector Initials

Application For Absent Voter'S Ballot

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