New York State Absentee Ballot Application
BOARD USE ONLY
Please print clearly. See detailed instructions.
Town/City/Ward/Dist:
___________________________
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 not
later than 7th day before election day. The ballot itself must either be personally delivered to
Party: ______________________
the board of elections no 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
voted in office
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 City on election day
patient or inmate in a Veterans’ Administration
temporary illness or physical disability
Hospital
permanent illness or physical disability
detention in jail/prison, awaiting trial, awaiting action
duties related to primary care of one or more
by a grand jury, or in prison for a conviction of a crime
individuals who are ill or physically disabled or offense which was not a felony
absentee ballot(s) requested for the following election(s):
2.
Primary Election only
General Election only
Special Election only
Any election held between these dates: absence begins: _____/_____/_____ absence ends: ______/______/______
last name or surname
suffix
first name
middle initial
3.
date of birth
county where you live
phone number (optional)
4.
4.
_______/_______/_______
address where you live (residence) street
apt city state
zip code
5.
NY
Delivery of Primary Election Ballot
Deliver to me in person at the board of elections
(check one):
6.
I authorize
to pick up my ballot at the board of elections.
(give name):
Mail to me at:
(mailing address)
____
street no. street name apt. city state zip code
Delivery of General (or Special) Election Ballot
Deliver to me in person at the board of elections
(check one):
7.
I authorize
to pick up my ballot at the board of elections.
(give name):
Mail to me at:
(mailing address)
____
street no. street name 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
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
:
_____/______/______
(Signature or Mark of Voter)
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 application 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 presence 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.
________________________________________________________________
________________________________________________________________ _____________________________________________
Board Use Only
(address of witness to mark)
(signature of witness to mark)