Absentee Ballot Request Form - Dubuque County Courthouse
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1S
I
O
A
B
R
F
TATE OF
OWA
FFICIAL
BSENTEE
ALLOT
EQUEST
ORM
*Indicates required information
F
O
U
O
OR
FFICE
SE
NLY
Mail to:
Last
Election Department
Y
N
*
OUR
AME
AND
First
Dubuque County Courthouse
D
B
*
ATE OF
IRTH
P.O. Box 5001
Middle
Suffix
Dubuque, Iowa 52004-5001
Date of Birth
/ /
(month, day, year)
Revised 7/1/2014
Iowa Driver’s License or Non‐Operator ID Number:
ID
N
UMBER
(Check and complete one)
Last Four Digits of Social Security Number: X X X – X X –
You must be registered to vote in the county to receive an absentee ballot. If you are registered to vote in the county, this form will be used to
Y
I
update your voter registration if the information provided on this form is different than the information on your registration record.
OUR
OWA
R
A
*
ESIDENTIAL
DDRESS
Home Street Address
(include apt, lot, etc. if applicable)
City
Zip
County
W
Y
HERE
OUR
Address/P.O. Box
A
B
BSENTEE
ALLOT
City
State
Zip
S
B
M
HOULD
E
AILED
(If different than above)
Country
(other than USA)
C
I
Phone
Email
ONTACT
NFO
General
Primary
School City Special:
E
T
D
*
LECTION
YPE OR
ATE
(Provide election type or date. Choose
OR
Election Date:
/ /
only one election.)
P
A
ARTY
FFILIATION
Primary Elections Only: check one political party
Democratic
Republican
I swear or affirm that I am the person named above and I am a registered voter or I am entitled to register at the address listed on this form.
R
A
*
EQUESTER
FFIDAVIT
I am eligible to receive and vote an absentee ballot for the election indicated above.
(Powers of attorney do not have legal
authority to request an absentee
ballot on behalf of another.)
Signature
Date
S
I
O
A
B
R
F
TATE OF
OWA
FFICIAL
BSENTEE
ALLOT
EQUEST
ORM
*Indicates required information
F
O
U
O
OR
FFICE
SE
NLY
Mail to:
Last
Election Department
Y
N
*
OUR
AME
AND
First
Dubuque County Courthouse
D
B
*
ATE OF
IRTH
P.O. Box 5001
Middle
Suffix
Dubuque, Iowa 52004-5001
Date of Birth
/ /
(month, day, year)
Revised 7/1/2014
Iowa Driver’s License or Non‐Operator ID Number:
ID
N
UMBER
(Check and complete one)
Last Four Digits of Social Security Number: X X X – X X –
You must be registered to vote in the county to receive an absentee ballot. If you are registered to vote in the county, this form will be used to
Y
I
update your voter registration if the information provided on this form is different than the information on your registration record.
OUR
OWA
R
A
*
ESIDENTIAL
DDRESS
Home Street Address
(include apt, lot, etc. if applicable)
City
Zip
County
W
Y
HERE
OUR
Address/P.O. Box
A
B
BSENTEE
ALLOT
City
State
Zip
S
B
M
HOULD
E
AILED
(If different than above)
Country
(other than USA)
C
I
Phone
Email
ONTACT
NFO
General
Primary
School City Special:
E
T
D
*
LECTION
YPE OR
ATE
(Provide election type or date. Choose
OR
Election Date:
/ /
only one election.)
P
A
ARTY
FFILIATION
Primary Elections Only: check one political party
Democratic
Republican
I swear or affirm that I am the person named above and I am a registered voter or I am entitled to register at the address listed on this form.
R
A
*
EQUESTER
FFIDAVIT
I am eligible to receive and vote an absentee ballot for the election indicated above.
(Powers of attorney do not have legal
authority to request an absentee
ballot on behalf of another.)
Signature
Date
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