New York State Absentee Ballot Application
Download a blank fillable New York State Absentee Ballot Application in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete New York State Absentee Ballot Application with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
New York State !bsentee Ballot !pplication
BOARD USE ONLY:
Town/City/Ward/Dist:
Please print clearly; See detailed instructions/
_________________________________
This application must either be personally delivered to your county board of elections not
Registration No: ____________________
later than the day before the election, or postmarked by a governmental postal service
Party: ____________________________
not later than 7th day before election day; The ballot itself must either be personally
delivered to the board of elections no later than the close of polls on election day, or
voted in office
postmarked by a governmental postal service not later than the day before the election and
received no later than the 7th day after the election/
I am requesting, in good faith, an absentee ballot due to (check one reason):
1/
absence from county or New York ity on election day
resident or patient of a Veterans Health
temporary illness or physical disability
!dministration Hospital
permanent illness or physical disability
detention in jail/prison, awaiting trial, awaiting
duties related to primary care of one or more
action by a grand jury, or in prison for a conviction
individuals who are ill or physically disabled
of a crime or offense which was not a felony
absentee ballot(s) requested for the following election(s) .
2/
General Election only
Primary Election only
Special Election only
!ny election held between these dates. absence begins. __
___/_____/_____ absence ends. _____/_____/_____
MM/DD/YYYY
MM/DD/YYYY
last name or surname
first name
middle initial
suffix
3/
MM/DD/YYYY
county where you live
phone number (optional)
email (optional)
date of birth
4/
_____ /_____ /_____
address where you live (residence) street
apt
city
state
zip code
5/
NY
Deliver to me in person at the board of elections
Delivery of Primary Election allot
(check one)
6/
I authorize
._______________________________________ to pick up my ballot at the board of elections/
(give name)
Mail ballot to me at.
(mailing address)
_______________________________________________________________________________________________________
street no/
street name
apt/
city
state
zip code
Deliver to me in person at the board of elections
Delivery of General (or Special) Election allot
(check one)
7/
I authorize
. ______________________________________ to pick up my ballot at the board of elections/
_
(give name)
Mail ballot to me at.
(mailing address)
________________________________________________________________________________________________________
street no/
street name
apt/
city
state
zip code
!pplicant Must Sign Below
I certify that I am a qualified and a registered (and for primary, enrolled) voter- and that the information in this application is
8/
true and correct and that this application will be accepted for all purposes as the equivalent of an affidavit and, if it contains a
material false statement, shall subject me to the same penalties as if I had been duly sworn/
X__________________________
____/____/____
Sign Here:
Date
MM/DD/YYYY
If applicant is unable to sign because of illness, physical disability or inability to read, the following statement
must be executed. y my mark, duly witnessed hereunder, I hereby state that I am unable to sign my applica-
tion for an absentee ballot without assistance because I am unable to write by reason of my illness or physical
disability or because I am unable to read/ I have made, or have the assistance in making, my mark in lieu of
my signature/ (No power of attorney or preprinted name stamps allowed/ See detailed instructions/)
Date ___/___/___ Name of Voter.____________________________________ Mark.___________________
MM/DD/YYYY
I, the undersigned, hereby certify that the above named voter affixed his or her mark to this application in my pres-
ence and I know him or her to be the person who affixed his or her mark to said application and understand that
this statement will be accepted for all purposes as the equivalent of an affidavit and if it contains a material false
statement, shall subject me to the same penalties as if I had been duly sworn/
_____________________________________________
______________________________________
_____________________________________________
(signature of witness to mark)
(address of witness to mark)
Board Use Only
2015 Absentee Ballot Application
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal