California Vote-By-Mail Ballot Application Form

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Vote-By-Mail Ballot Application
Calaveras County
FOR OFFICIAL USE ONLY
891 Mountain Ranch Road
San Andreas, CA 95249
Phone: (209)754-6376
Rev. 4/2016
Enter the date of the election and the type of election (e.g., Primary, General, or Special). This application must be received by your
county elections official not later than seven (7) days prior to the date of the election. The date of the election can be found at
A ballot will not be sent to you if this application is incomplete or inaccurate.
1. This is an application for a vote-by-mail ballot for the ____________________, __
_________________________________
election
.
Month/Day/Year
Type of Election (Primary, General, or Special)
2. Print name: ____________________________________________________________
___
3. Date of birth: _________________
___
First
Middle Name or Initial
Last
Month/Day/Year
4. Residence address: ___________________________________________________________________________
_________________
Number and Street (P.O. Box, Rural Route, etc. will not be accepted)
(Designate N, S, E, W if used)
____________________________________________________________________________________________
City
Zip Code
California County
5. Mailing address for ballot (if different from above):
If your mailing address is outside of the U.S., and you are a military or overseas voter, re-register at RegisterToVote.ca.gov or use the Federal Post Card Application
at
_____________________________________________________________________________________________________________
Number and Street/P.O. Bo
x (
Designate N, S, E, W if used)
_____________________________________________________________________________________________________________
City
State or Foreign County
Zip Code or Postal Code
6. Telephone number (optional): (_____) ____________________
(_____) ____________________
Day
Evening
7.
(Only complete Item 7 if this application is for a Presidential Primary Election.)
Yes, I want to request a political party ballot for the Presidential Primary Election.
I have declined to disclose a preference for a qualified political party. However, for this primary election only, I request a vote-by-mail ballot for
the ________________________________________ Party.
Write in only one party: American Independent, Democratic or Libertarian
Under California Law, qualified political parties may allow registered voters with “No Party Preference” to crossover and vote in their parties. For the June 7, 2016 Presidential Primary
Election, the American Independent, Democratic and Libertarian parties have allowed “crossover voting”. If you are registered as “No Party Preference” and do not wish to request a
“crossover” ballot, no action is required. To request a “crossover” ballot, write in your choice above.
8.
Yes, I want to become a permanent vote-by-mail voter.
By checking this box and by initialing here _____, I am requesting to become a permanent vote-by-mail voter. A vote-by-mail ballot will automaticall
y
be sent to me in all future elections. I understand that if I fail to vote by mail in four consecutive statewide general elections, I will need to reapply for
permanent vote-by-mail voter status.
9. This application must be signed.
I have not applied for a vote-by-mail ballot from any other jurisdiction for this election. I certify under penalty of perjury under the laws of the State of California
that the information I have provided on this application is true and correct.
Signature: ______________________________________________________________
Date: ______________________________
Warning: Perjury is a felony, punishable by imprisonment in state prison for up to four years. (Penal Code § 126)
NOTICE
You have the right to mail or deliver this application directly to your county elections official.
Returning this application to anyone other than your county elections official may cause a delay that could interfere with your ability to vote.
If this application is returned by mail, it must be returned directly to your county elections official.
Only the registered voter himself or herself may apply for a vote-by-mail ballot. An application for a vote-by-mail ballot made by a person other than the
registered voter is a criminal offense.
Individuals/Organizations/Groups Distributing this Application
The format used on this application must be followed by anyone distributing vote-by-mail ballot applications. Failure to conform to this format is a crime.
Anyone distributing this application may not preprint a mailing address in Item 5.
Anyone distributing this application may not preprint a check mark or political party name in Item 7.
Anyone providing this application to a voter must enter their name, address, and telephone number here: ____________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________

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