Form 3a - Official Absentee Ballot Request Form

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State of Iowa
*
Offi cial Absentee Ballot Request Form
REQUIRED Information
Form 3A (Rev 01-08)
*
If you don’t have an Iowa driver’s license or non-operator ID, provide the last 4 digits of your Social Security Number.
Date of Birth
Valid IA Driver’s License or IA Non-Operator ID Number
1.
Last 4 Digits of SSN #
/
/
Ye a r
OR
( M o n t h / D a y / Ye a r )
FOR OFFICE USE ONLY
*
Last Name
First Name
Middle Name
Suffi x ( Sr., Jr., etc.)
Name
2.
*
Street Address (include apt., lot, etc., if applicable)
*
ZIP
City
State
Daytime Phone, Cell Phone or Email
Former Name (if applicable)
3.
The above address represents my NEW address.
I have moved.
Please change my voter record accordingly.
Complete section #4 ONLY if the ballot is to be mailed to an address different than the address in section #2.
Mailing Address (include apt., lot, etc., if applicable)
4.
State
ZIP
City
Country (other than USA)
*
OR
Date of the Election
Name of the Election for this Absentee Ballot Request
Party Affi liation
(for Primary Elections Only)
Check only
General
Primary
School
5.
/
/
ONE
Democratic
Republican
Box
NOTE: If your voter registration record shows a political party different from the one you check above,
( M o n t h / D a y / Ye a r )
City
Special ________________
your registration will be changed to the political party you check on this form.
*
6.
X
________________________________________________________________________________
_________________________________
Signature of Voter
Date

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