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Form Av7 - Application For Advance Voting Ballot By A Former Precinct Resident - Kansas Secretary Of State

Application for Advance Voting Ballot

AV7

by a Former Precinct Resident

Affirmation of a Former Precinct Resident of the County of

, and State of

Kansas Desiring to Vote an Advance Voting Ballot

State of

(where application is completed)

County of

(where application is completed)

I do solemnly affirm that I have moved from my former residence on

Date

I am entitled to vote an advance voting ballot and I have not and will not otherwise vote at the

election to be held on

Primary, General or Special

Date

Former Residence:

Name

Residence

City/State/Zip

Ward/Pct/Twp

Current Residence:

*Mail ballot to:

(Complete if mailing address is different.)

Residence

City/State/Zip

Ward/Pct/Twp

Political Party

(Complete only when requesting primary election ballots.)

Signature of Voter

Note: False statement on this affirmation is a severity level 9, nonperson felony.

For office use:

Date App. Rec'd.

*NOTE: The ballot may be mailed only to the voter's resi-

dential or mailing address as indicated on the county voter

Ballot Mailed

registration list, to the voter's temporary residential address,

or to a medical care facility where the voter resides. These

Voted in Office

restrictions do not apply to sick, disabled or illiterate voters.

Transmitted by

Prepared by the Office of Secretary of State Kris W. Kobach, 1st Floor, Memorial Hall, Topeka, KS 66612-1594

K.S.A. 25-1122d(d), 25-3702

Rev 1/26/11 jdr

Form Av7 - Application For Advance Voting Ballot By A Former Precinct Resident - Kansas Secretary Of State

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