State Of Iowa Official Absentee Ballot Request Form
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1
2S
I
O
A
B
R
F
COLLINS-MAXWELL COMMUNITY SCHOOL DISTRICT
TATE OF
OWA
FFICIAL
BSENTEE
ALLOT
EQUEST
ORM
*Indicates required information
F
O
U
O
OR
FFICE
SE
NLY
Last
Y
N
*
OUR
AME
AND
First
VOTE ON SEPTEMBER 8, 2015
D
B
*
ATE OF
IRTH
Middle
Suffix
$8.175 MILLION BOND REFERENDUM + INCREASE THE PHYSICAL PLANT AND EQUIPMENT LEVY BY $0.67
Date of Birth
/
/
(month, day, year)
Revised 8/1/2013
MIDDLE SCHOOL/HIGH SCHOOL
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
I
A
W
update your voter registration if the information provided on this form is different than the information on your registration record.
OWA
DDRESS
HERE
Y
A
R
OU
RE
EGISTERED
Street Address
(include apt, lot, etc. if applicable)
V
*
TO
OTE
City
Zip
County
W
Y
HERE
OUR
Address/P.O. Box
A
B
BSENTEE
ALLOT
City
State
Zip
S
B
M
HOULD
E
AILED
B
(If different than above)
Country
(other than USA)
C
I
ONTACT
NFO
Phone
Email
General
Primary
School
City
Special:
E
T
D
*
LECTION
YPE OR
ATE
(Provide election type or date)
0
0
8
0
OR
Election Date:
9
/
/
2
1
5
P
A
ARTY
FFILIATION
Primary Elections Only: check one political party
Democratic
Republican
A
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
H
S
I
O
A
B
R
F
TATE OF
OWA
FFICIAL
BSENTEE
ALLOT
EQUEST
ORM
*Indicates required information
F
OR
O
FFICE
U
SE
O
NLY
C
Last
Y
N
*
G
OUR
AME
AND
First
D
B
*
ATE OF
IRTH
Middle
Suffix
Date of Birth
/
/
F
(month, day, year)
Revised 8/1/2013
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 –
E
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
I
A
W
update your voter registration if the information provided on this form is different than the information on your registration record.
D
OWA
DDRESS
HERE
Y
A
R
OU
RE
EGISTERED
Street Address
(include apt, lot, etc. if applicable)
V
*
TO
OTE
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)
Existing Building
Classrooms
E
A
C
I
ONTACT
NFO
Phone
Email
E
T
D
*
General
Primary
School
City
Special:
LECTION
YPE OR
ATE
Mechanical Room
Toilets
F
B
(Provide election type or date)
0
OR
0
9
8
2
0
1
5
Election Date:
/
/
P
A
ARTY
FFILIATION
Primary Elections Only: check one political party
Democratic
Republican
Office Renovation
Science Classrooms
G
C
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
Mechanical
Weight Room/Multi-Purpose
authority to request an absentee
D
H
ballot on behalf of another.)
Signature
Date
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