Fillable Montgomery County Ny Absentee Ballot Application Form (Page 2 of 2) in pdf

Montgomery County NY Absentee Ballot Application

BOARD USE ONLY:

Registration No:____________________

T/W/D: __________________________

This application must either be personally delivered to your county board of elections not later than

the day before the election, or postmarked by a governmental postal service not later than 7th day

Party: ____________________________

before election day. The ballot itself must either be personally delivered to the board of elections no

Absentee Type: ____________________

later than the close of polls on election day, or 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.

Commissioners Initials

See detailed instructions on back

Reset Form

___________/___________

last name or surname

middle initial

suffix

first name

county in NY state where you live

date of birth

phone number

(optional but helpful if contact is needed)

______/______/_______

apt

address where you live (residence) street

c it y

st at e

z i p c o de

I am requesting, in good faith, an absentee ballot due to (Choose one reason)

absence from county or New York City on election day

resident or patient of a Veteran's Health Administration

Hospital

temporary illness or physical disability

permanent illness or physical disability

detention in jail/prison, awaiting trial, awaiting action by

a grand jury, or in prison for a conviction of a crime or

duties related to primary care of one or more

offense which was not a felony

individuals who are ill or physically disabled

Select

to request absentee ballot(s) for the following election(s) (Note: Application only valid through 12/31 of calendar year)

Special Election ONLY

General Election ONLY

Primary Election ONLY

Select the section below with specified dates if you are applying for more than one election.

absence ends:

Any Election held between these dates: absence begins:

Delivery of Primary Election Ballot

(select one)

Deliver to me in person at the board of elections

I authorize (give name):_______________________________________ to pick up my ballot at the board of elections.

Mail ballot to me at:

(mailing address)

_______________________________________________________________________________________________________

street name or PO Box

city

state

zip code

street no.

apt.

Delivery of General (or Special) Election Ballot

(select one)

Deliver to me in person at the board of elections

I authorize (give name):_______________________________________ to pick up my ballot at the board of elections.

Mail ballot to me at:

(mailing address)

_______________________________________________________________________________________________________

street name or PO Box

street no.

apt.

city

state

zip code

Applicant 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

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.

Sign Here: X___________________________________Date:________________

If applicant is unable to sign because of illness, physical disability or inability to read, the following statement

must be executed: By 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:___________________

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)

Board Use Only

(address of witness to mark)

2010 regular ab app2_rev (6/15/10)

Montgomery County Ny Absentee Ballot Application Form Page 2

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